HX00018813 Bine: hM wii;iii«i time Operating Room. The dome-amphitheater, Massachusetts General Hospital. The first public demonstration of ether anesthesia, October 16, 1846. (After the well-known painting, m the Boston Medical Library, by Hobert Hinckley.; Fig. 2. — A Modehn Oper.\ting Room. The Bifielow amphitheater, Massachusetts General Hospital. A meetinK of the Society of Clinical Surgery, May 1, 1908. THE PRACTICE OF SURGERY BY JAMES GREGORY MUMFORD, M. D. VISITING SURGEON' TO THE MASSACHUSETTS GENERAL HOSPITAL; INSTRUCTOR IN SURGERY IN THE HARVARD MEDICAL SCHOOL," FELLOW OF THE AMERICAN SURGICAL ASSOCIATION, ETC. IVITH 682 ILLUSTRATIONS PHILADELPHIA AND LONDON W. B. SAUNDERS COMPANY 1910 /3- ^K^b'/ Copyright, 1910, by W, B. Saunders Company PRESS OF AUNDERS COM PAN Y = H I U A D E l_ P H I A f) To my friends and associates in the Society of Clinical Surgery The Wisdom of God receives small honour from those vulgar Heads that rudely stare about, and with a gross rusticity admire His works: those higlily magnifie Him, whose judicious inquiry- into His Acts, and deliberate research into His Creatures, return the duty of a devout and learned admiration. Religio Medici. PREFACE In this writing I present a short treatise on the Practice of Sur- gery. Perhaps the title '' CHnical Surgery" would equally describe the work. I omit consideration of the 'princi'ples of surgery, except incidentally and when the course of the argument seems to call for such consideration. Within youthful memory even the field of surgery has broadened so enormously; so many new subjects have come within its embrace ; knowledge of its manifold expression has become so exten- sive ; its study is now found to expand into so many branches, and its roots to penetrate so deeply, that a sound, comprehensive knowledge of all its parts is no longer possible to a single individual, or to be con- densed as I wish to condense this work. When men of my generation were young their studies in surgery were regarded as reasonably complete when they had grounded themselves in gross and surgical anatomy, in general pathology, in such simple bac- teriology as was then taught, and in operative technic. To-day studies in surgery embrace an immensely wider field. Surgical pathology has grown until that branch alone has become the object of a teacher's undivided efforts. Special inquiry into particular diseases, processes, and lesions absorbs individual investigators. Studies in bacteriology, in questions of immunity, in serum and opsonic therapy, in the blood, in tumors, in neurologic surgery, in gastro-intestinal surgery, in dis- eases of the eye, the ear, the throat ; in surgical physiology and number- less kindred topics, have become so far reaching and diffuse that no one mind can master their infinite variety. The situation is different from what we knew when a single teacher could instruct his classes in all there was to know of surgery; when a general surgeon was thought competent to practice in every field. To-clay the practitioner, as well as the student, must acquire knowl- edge in special laboratories, under special teachers, and from special books, before he is thought competent to take up his clinical work ; while clinical work and teaching alone, with such a background of study as I have described, must be the task of specially qualified persons, whose function it is to follow the 'practice of surgery. Every surgical clinician ma}^ have his particular interest, his skill in some branch of knowledge or research, but he cannot be a sound exponent of all surgical knowl- edge. And so it must be with a treatise on the Practice of Surgery. As a general surgeon, I may not attempt to deal comprehensively, accurately, and scholarly with all branches of surgery. Writers of 8 rilEFACE text-books on Medical Practice have learned something of this. They no longer fill their pages with elaborate essays on theory as well as on practice. In this book, accordingly, I give to the reader an account of the prac- tice of surgery — of surgery as he will see it at the bedside, in the accident ward, and in the operating-room. The writing is elaborated from many years of active hospital and private surgical practice, from clinical teachings, from class-room discussions, and lectures. With proper modesty may I hope that the student will find here a com])rc- hensive description of all such general surgical ailments as may fall to him for treatment and advice. Moreover, the reader will find the plan of this book somewhat un- conventional in other respects. I puipose taking up surgical diseases in their order of interest, importance, and frec|uency, so far as one may with due regard to a proper sequence; and I endeavor also to lay stress on those subjects which nature herself has accentuated. By such a plan one should be able to present the various subjects in their true perspective. Appendicitis concerns us far more than does inflammation of Meckel's diverticulum; meningitis, than cirsoid aneurysm; and felon, than Dupuytren's contraction. The student should leani to look for, to recognize, and to treat the common and grave ailments which practice furnishes. Curiosities of surgery should be known, but their infrequency will limit their familiar study by the average practitioner. For this reason their exhaustive exposition must be left to writers of especial monographs. Frequently one finds essayists complaining that their own immediate topics are slighted by the writers of text-books. In the nature of text-book composition such slighting is inevitable. A text- l)ook of surgery cannot be an encyclopedic treatise on all surgical knowledge. In this book, therefore, I assume the reader's preliminary training, and endeavor to present to him the Practice of Surgery as surgeons see it — as a subject of unending variety and importance, as a pursuit of the deepest human interest. I thank cordially my friends who have assisted me by their criticism in the final revision of the manuscript: Dr. Malcolm Storer, Dr. Thomas F. Harrington, Dr. E. W. Taylor, Dr. R. B. Greenough, Dr. Lincoln Davis, Dr. Samuel Robinson, and Dr. John B. Hartwell. The original illustrations are by Miss Ruth O. Huestis, an indefatig- able artist. J. G. M. 29 Commonwealth Ave., Boston, Mass., September, 1910. CONTENTS PART I— THE ABDOMEN CHAPTER I PAGE Appendicitis 17 FoiTus of Appendicitis 23 Symptoms of Appendicitis 26 Diagnosis of Appendicitis 30 Treatment of Appendicitis 31 CHAPTER II The SiL\LL IXTESTINE AND COLON 42 Symptoms 46 Intestinal Obstruction 47 Injuries 54 Foreign Bodies 56 Meckel's Diverticulum 57 Enteroptosis 60 Colitis 63 Typhoid Perforation ■ 64 Tuberculosis of the Intestines 67 Actinomycosis of the Intestines 69 Embolism and Thrombosis of the Mesenteric Vessels 71 Intussusception 73 Volvulus 75 Internal Hernise 76 Idiopathic Dilatation of the Colon 76 Tumors of the Intestine 76 Fecal Fistula and Artificial Anus 82 The Mesentery and Omentum 87 CHAPTER III The Rectum and Anus 89 Hypertrophy of the Rectal Valves 90 Imperforate Anus 90 Inflammations 92 Fissure of the Anus 94 Ischiorectal Abscess 95 Fistula in Ano 97 Hemorrhoids , 99 Prolapse of the Anus and Rectum 102 Stricture of the Rectum 104 Tumors of the Anus and Rectum 105 CHAPTER IV The Esophagus, Stomach, and Duodenum 113 The Esophagus 114 Stricture of the Esophagus 115 Cardiospasm 120 Diverticulum of the Esophagus 122 Foreign Bodies in the Esophagus 123 Tumors of the Esophagus 125 Injuries of the Esophagus 126 Inflammations of the Esophagus 127 9 10 CONTENTS Thk Esophagus, Stomach, axd Dtodp.nt.m (Continued). paoe The Stomach 127 Peptic Ulcer 12'.i Pyloric OVxstructiou 131) Ili'iuorrliii^c 141 Perforation 142 Distortion of the Stomach 142 Gastric Adhesions 143 Gastric Tetany 144 Gastric Cirrhosis 144 Spasm of the Pylorus 144 Gastroptosis 144 Stenosis of the Pylorus 1 45 P'oreign Bodies 145 Cancer 145 Sarcoma 153 Wounds 154 CHAPTER V The Liver and Bile-passages 155 The Liver 155 Abscess of the Liver 156 Cysts of the Liver 157 Injuries of the Liver 158 Tumors of the Liver 159 Cirrhosis of the Liver 163 Hepatoptosis .^ 165 The Bile-passages 167 CHAPTER VI The Pancreas and Spleen 181 The Pancreas 181 Inflammations — Pancreatitis 181 Tumors 184 Traumatic Injuries 186 The Spleen 187 Injuries 187 Abscess and Tuberculosis 188 Cysts 188 Neoplasms 189 Splenic Enlargement 1 89 Ptosis 190 CHAPTER VH Abdominal Hernia 192 Inguinal Hernia 199 Femoral Hernia 213 Umbihcal Hernia 215 Ventral Hernia 219 Diaphragmatic Hernia 220 Obturator Hemia 221 Retroperitoneal Hemia 221 CHAPTER YUI Peritoneum and Retroperitoneal Space 223 Acute Peritonitis 223 Diffuse Peritonitis 225 Chronic Peritonitis 234 The Retroperitoneal Space 238 CHAPTER IX Ptosis of the Abdominal Organs — The Abdominal Wali 243 Abdominal Ptosis 243 The Abdominal Wall 251 CONTENTS 11 PART II— FEMALE ORGANS OF GENERATION CHAPTIOR X PACE The Uterus 255 Aiuitoinj' 255 Inttaiuiuatiou 261 Lacerations 272 Wounds 274 Displacements 275 Tumors 292 Myoma 292 Cancer 305 Endothelioma 317 Sarcoma 317 Deciduoma Malignum 318 CHAPTER XI Fallopian Tubes and Ovaries 319 The Fallopian Tubes 319 Salpingitis 319 Tumors 329 The Broad Ligaments 330 The Ovaries : 331 Ovaritis 331 Tumors 333 Tubal Pregnancy 340 Pelvic Hematocele 344 CHAPTER XII Perineum and Vagina 345 Perineal Lacerations 345 Urethral Caruncle 352 The Vulva 352 The Vagina 353 Vaginal Fistulse 353 Inflammation 357 Vaginal Cysts 357 Atresia of the Vagina 357 PART III-GENITO-URINARY ORGANS CHAPTER XIII Kidneys and Ureters 358 Anatomic Relations 358 Diagnosis in Renal Disease 360 Injuries of the Ividney , 366 ■Stone in the Ividney 369 Hydronephrosis 374 Pyelitis 375 Tuberculosis of the Kidney 380 Tumors of the Ividney and Suprarenal Gland 382 Lumbar Fistula " 386 Chronic Nephritis 386 CHAPTER XIV Bladder and Prostate 388 The Bladder 388 Exstrophy of the Bladder 388 12 CONTENTS Bladdkh and Prostate (Continued). page Absence of the Bladder, Double Bladder :i8*J Reteiit ion of Urine 390 Cystitis 394 Stone in the Bladder 398 Uleer of the Bladder 404 Tumors of the Bladder 40."> Sacculation of the Bladder 408 Bladder Injuries 409 The Prostate 411 Anatomy of the Prostate 411 Inflammation of the Prostate 412 Prostatic Calculi 414 Hypertrophy of the Prostate 415 Cancer of the Prostate 428 CHAPTER XV Penis, Urethra, and Testes 433 The Penis and Urethra 433 Gonorrhea 434 The Genital Lesions of Syphihs 444 Injuries of the Penis 447 Genital Herpes 448 Venereal Warts 448 Circvmacidon 448 Cancer of the Penis 450 Foreign Bodies in the Urethra 451 Para-urethral Abscess 452 Stricture of the Urethra 452 Urethral Fistula 458 ITrethroscopy 458 Hypospadias and Epispadias 459 The Testicles 464 Undescended Testicle 464 Wounds and Contusions 468 Inflammation ' 468 Hydrocele 470 Varicocele 474 Tumors 475 Twisted Cord 477 Castration 477 PART IV— THE CHEST CHAPTER XVI The Bronchi and Lungs 478 Foreign Bodies in the Bronchi 479 Bronchiectasis 480 General Teclmic of Operating upon the Lungs 481 CHAPTER XVII The Pleura 488 Inflammatory Disease 488 Pyothorax 490 CHAPTER XVIII The Heart and Pericardium 496 Pericardial Effusions 497 Operations upon the Pericardium 497 Wounds of the Heart 499 CONTENTS 13 CHAPTER XIX PAGE The Chest- wall — The Breast 502 The Chest-wall 502 Contusions of the Chest 502 Inflammations 503 Neuritis of the Intercostal Nerves 504 Tumors of the Chest-wall 504 The Breast 505 Anatomy 505 Cancer 507 Other Breast Tumors 524 Mastitis 529 Retention Cysts 532 Supernumerary Breasts and Nipples 532 PART V— THE FACE AND NECK CHAPTER XX Harelip and Cleft-palate 533 Harelip 534 Cleft-palate 540 Plastic Operations on the Face 544 Salivary Fistula 547 Salivary Stones 547 Ranula 547 Thyrolingual or Thyroglossal Cysts and Sinuses 548 Cancer of the Lip 548 Rodent Ulcer 554 Injuries of the Face 555 Tumors of the Face 556 CHAPTER XXI Jaws, Tongue, Larynx, and Pharynx 558 The Jaws 558 Infections 559 Tumors 561 The Tongue 569 Inflammation 570 Cancer 571 Sarcoma 574 The Salivary Glands 574 The Pharynx and Nasopharynx 576 Diseases of the Larynx ■ 578 CHAPTER XXII The Neck 586 Cicatricial Contractions . . . : 586 Torticollis 586 Cervical Adenitis 589 Wounds of the Thoracic Duct 593 Deep Cervical Abscess 594 Pediculi Capitis 594 Lymphatic Cysts 594 The Carotid Gland 595 Cervical Rib 597 Disease of the Thyroid Gland 597 Goiter 602 Epithelial Diseases of the Thyroid 610 14 CONTEXTS PART VI— THE HEAD AND SPINE CHAPTER XXIII PAGE The Scalp 613 Contusions of the Scalp 614 Tumors of the Scalp 616 CHAPTER XXIV The Skull, Brain, and Meninges 619 Fractures of the Skull 620 The Meninges 642 Developmental Anomalies 643 Hj'drocephalus 644 Cerebrospinal Rhinorrhea 645 Sinus Thrombosis 646 Meningitis 647 Meningeal Tumors 650 The Cranium 650 Tumors of the Cranial Bones 650 The Brain 652 Encephalitis 652 Cerebral Abscess 652 Tumors of the Brain 653 Results of Injuries and Diseases of the Brain 658 Intracranial Operations 663 CHAPTER XXV The Spixe and the Peripheral Xerves 669 The Spine . 669 Anatomy and Physiologj- of the Cortl 670 Concussion and Contusion <)74 Wounds of the Cord .' 675 Dislocations and Fractures of the \'ertel3rse 676 Spinal Meningitis ■ 680 Spina Bifida 681 Tumors of the Spine 685 The Peripheral Xer\'es 694 X'euritis 695 Xeuralgia 697 Operations upon the Xer\es 707 PART VII-MINOR SURGERY. DISEASES OF STRUCTURE CHAPTER XXVI Minor Surgery 719 The Examination and Study of Cases; Wounds: Fractures; Local Infec- tions: Massage 719 Incised Wounds ■ 724 Simple (Closed ) Fractures 729 Lacerated Wounds 732 Compound ( Open) Fractures 736 Granulating Wounds and Varicose Ulcers ^40 Felon: Whitlow; Paronychia: Palmar Abscess 745 Boils: Carbuncles 'j2^ Bunions; Ingrowing Nails; 'Corns; Warts i_'>( Massage '^^ CONTENTS 15 CHAPTER XXVII PAGE Shock; Blood-vessels; Lymphatics; Muscles; Tendons; Burs.e; Skin... 767 Shock and Collapse "67 Suro;eiy of the Blood-vessels 772 " Pfdebitis "73 Angioma 776 The Arteries 776 Ligation of the Arteries 776 Aneurysm 783 Suture of the Blood-vessels 792 Surgeiy of the Lymphatic System 792 Lymphangitis 794 Lymphangioma, Lymph Varices, Lymphangiectasis, and Lymphaden- ocele 796 Lymphadenitis 798 Hodgkin's Disease 799 Surgery of the Muscles, Tendons, and Bursse 801 Muscles 801 Tendons 803 Bursa? 808 Surgery of the Skin 812 CHAPTER XXVIII Tumors 818 Classification : . . . . 819 Causation 819 Cysts 820 Dermoids and Teratomata , 824 Tumors of the Connective-tissue Type 826 Epithelial Tumors 838 Cancer 842 CHAPTER XXIX Fractures and Dislocations 849 Fractures 849 General Considerations 850 Simple Fractures 854 Compound Fractures • 858 Special Fractures and their Treatment 859 Ribs 859 Sternum 861 Pelvis 862 Clavicle 863 Scapula 867 Humerus °"° Elbow , 877 Forearm 884 Colles' Fracture 886 Carpus 891 Metacarpal Bones 892 Phalanges 895 Femur 895 Patella 904 Leg 907 FoSt 916 Face 917 Pathologic Fractures 9^4 Dislocations 9-4 Special Dislocations 926 16 CONTEXTS CHAPTER XXX PAGE Bones and Joints (Okthoi'edic Surgery) 943 The Hones 943 Tlie Joints 955 CHAPTER XXXI Amputations 974 Special Amputations 981 Index 993 THE PRACTICE OF SURGERY PART I THE ABDOMEN CHAPTER I APPENDICITIS Appendicitis, more than any other acute disease, interests all classes of the community. It is everywhere present; it is serious and alarming; it appears under many guises and passes through many phases; it calls for heroic treatment; its study has been developed and formulated in our own generation, and so has become a favorite theme of modern surgeons ; about it have centered some of the most stimulating and vital medical discussions of our time, and in the great majority of cases it can be cured. The history of appendicitis is recent, because so lately as 1886 only was its nature properly demonstrated, "^ but for generations there were knowledge and fear of attacks of pain and inflammation, often fatal, in the right lower portion of the abdomen. Sporadic accounts of cases appear far back in medical literature, and are recorded by French, Italian, and English reporters of the last three centuries. In the nineteenth century, and with the development of abdominal surgery, following Lister's teaching, our attack upon this disease became more concentrated and effective. The Englishman Hancock, and the New York surgeons Willard Parker and Gurdon Buck, opened abscesses in the right iliac fossa fifty years ago. In 1886 R. H. Fitz, of Boston, ex- plained the nature of the process, while J. Homans, C. McBurney, C. B. Porter, M. H. Richardson, J. B. Deaver, and many recent operators have developed and perfected a technic for dealing with the disease in both its acute and quiescent stages. The anatomy of the vermiform appendix is important. The little organ lies in the right iliac and hypogastric regions, in its typical posi- tion hanging down over the brim of the pelvis ; but it may swing in any direction, from its base as an axis. Occasionally it lies entirely behind ^ R. H. Fitz, Perforating Inflammation of the Vermiform Appendix, Trans. Assoc. Amer. Physicians, June, 1886. 2 17 18 THE ABDOMEN the cecum. Its most common length is between 2 and 3.2 inches; rarely, one sees removed a great appendix, 5, 9, and even 10 inches long. The lumen is from 0.1 to 0.2 inch in diameter. At its entrance into the cecum is a fold of mucous membrane known as the valve of Gerlach. Fig. 3. — Normal vermiform appendix. In a few reported cases no appendix has been found. Let me remind the . student that in the development of the fetus the cecum and appendix descend from high up under the liver, in which position the appendix is Fig. 4. — Diagram showing unusually long appendix. an organ of considerable size.* At the fourth month of intra-uterine life the size of the appendix is to the cecum as about 1 is to 5. At birth it approximates to the adult size and foi-m, its proportion to the cecum 1 In herbivora no true appendix is found, but a large, useful, and dilatable second cecal pouch. In carnivora this pouch has shrunk to the apparently useless appendix or has disappeared. APPENDICITIS 19 bein"- about 1 to 15. As infancy and youth advance, this disproportion becomes more and more marked, until the cecum has overgrown and crowded the appendix to such an extent that the latter has been pushed upward, backward, and usually inward, so as to appear as a mere spiral Ficr 5 —Normal position of appendix and cecum with transverse colon raised; ^' ' dotted line showing natural position of transverse colon. projection from the posterior aspect of the cecum. This position it reaches about the fifth year. Commonly, one finds the appendix swinging loosely in a fold of peritoneum, which forms its mesentery,— the meso-appendix,— and carries its blood-supply, nerves, and lymph- vessels. 20 THE ABDOMEN The artery of the appendix' springs from the superior mesenteric, and feeds the organ through a number of branches. The nerve distribu- tion is shared with the small intestine and the stomach; the muacular mechanism runs to the cecum.- The significance of this divergent arrangement will be seen when we consider the etiology of appendicitis. "While the wall of the appendix resembles that of the cecum, its mucous membrane is far richer in lymph-glands, which are intimately concerned wath its inflammatory processes. The organ practically is always CO vexed with peritoneum, but its freedom of movement and its variable position have an im})ortant bearing on the extent and severity of inflammation originating in it. When free in the general peritoneal cavity, it is obviously a source of more serious danger than when tucked away behind the cecum .^ The function, or lack of function, of the vermiform appendix is the subject of an interesting chapter, and the question is closely allied to the rather intricate anatomy at which we have glanced. The process of shrinking of the appendix by no means stops with the fifth year.* Obliteration continues. From the fifteenth year on a small but increas- ing proportion of appendices are found to be cut off from the gut, through changes in their mucous lining. By the thirty-fifth ^-ear this proportion is said to have reached 25 per cent., and so on until, by the sixty-fifth year, it has reached nearly 70 per cent. This corresponds to the lessened liability to appendicitis with advancing years. On the other hand, the appendix, or cecoappendix, as the complete cecum- plus-appendix has been called, appears to have a distinct function in secreting a fluid which aids in digestion and absorption and in controlling materially the action of the bacteria always present there in great numbers." In the etiology of appendicitis we find that the various factors already mentioned have an immediate bearing upon the process. It is obvious that appendicitis is of bacterial origin, and the question is, How do the bacteria gain a lodgment in the tissues and produce dis- turbance? Pus-cocci and the Bacterium coli commune are the most common offenders. We know that bacteria, when they are retained under pressure, may enter into the tissues. A congestion of the cecal mucous membrane ma}' obstruct the valve of Gerlach; the appendix then becomes distended with mucus loaded with bacteria; localized 1 A secondary blood-supply in women is sometimes described as reaching the appendix tlirough tlie appendiculo-o\-arian or, more properly, the suspensory ligament. Such a blood-supply, as well as a lymphatic supply by the same route, is problematic, though it has occasionally been descrilied. Embrj'ologicany, it is a paradox {vide. D. H. Craig, Clinical Experiences with the Appendiculo-ovarian Ligament, Amer. .Jour. Obstet. and Dis. of ^A■omen, 1904, vol. 1, No. 3. 2 McEwen, Function of Cecum and Appendix, Lancet, October 8. 1904. 3 W. A. Brooks, .Jr., Boston Med. and Surg. Jour., 190.S, vol. cliii. p. 358, refers to a "subject of a sixteen-year-old girl at tlie Harvard Medical Sciiool. . . The ascending colon is completely unattached to the posterior abdominal wall, except by the root of its me.senterj'. The appendi.x may be placed at almost any point in the abdominal cavity." * Woods Hutchinson, Appendicitis as an Incident in Development, Amer. Med., August 1, 1903. 5 McEwen, ibirf. APPENDICITIS 21 necrosis follows; the bacteria enter the tissues, and the mischief is done.^ McEwen- makes the observation that since the appendix shares in the nerve distribution of the small intestine and stomach, therefore, under normal conditions of health, food high up in the gut stimulates the appendix, which proceeds to pour out its secretion long before the chyle reaches it. Conversely, irritating substances in the stomach or small intestine will disturb the nerve mechanism of the appendix, so that its secretion is checked, and the cecum remains dry; consequently bacteria multipl}^ and act viciously, especiall}' if there be temporary obstruction to the outlet of the appendix. Such irritation and obstruc- tion will prove a still more serious matter if the appendix be adherent or kinked from a previous inflammation, or if the normal process of •Fig. 6. — Valves of the ileum and appendix (open and closed). obliteration has caused stenosis of the appendix outlet.^ The ancient impression that these appendix inflammations are due to foreign bodies or even to fecal concretions lodged in the appendix is seldom true, though it is conceivable that such a body might close the valve of Ger- lach* or even cause mechanical erosions, with a consequent train of destructive changes. Alterations in the blood-supply of the appendix were at one time regarded as the cause of appendicitis, but although such arterial changes ^ C. Van Zwalenburg, Jour. Amer. Med. Assoc, March 26, 1904, under the cap- tion, Obstruction and Consequent Distention the Cause of Appendicitis, records some interesting observations bearing on this point. - Ibid. 3 Ribbert and Zuckerkandl found a partial or complete closure of the appendix in about 25 per cent, of the cases examined. •*The existence of which is questioned by George Woolsey and other sotmd writers. 22 THE ABDOMExX are found, it is likely that they are usually secondary and not primary. Exposure to cold, influenza, and rheumatism have been mentioned as causes of appendicitis, through their producing swelling of the mucosa and obstruction of the lumen. There is little evidence that such causes are frecjuent. Pathologic Anatomy. — Any surgeon of experience will tell you that he learns something new from every case of appendicitis, because cases differ so constantly in detail, and because, frequently, the symptoms and signs fail as guides to the conditions actually present. The terms appendiceal colic, catarrh of the appendix, hydrops of the appendix, acute appendicitis, gangrenous appendicitis, relapsing appendicitis, chronic appendicitis, etc., are common. Let us study the conditions which may justify these terms. Bearing in mind the normal obliterative process which is seen in great numbers of appendices, we must conclude that this process of obliteration may enter at times into the problem of abnormal pathologic conditions. It does not seem pro))able that ''appendiceal colic" is a term which should be apphed to any clearly recognized process. At any rate, if there be such a condition, it is not demonstrable. But there may be, and unquestionably are, colicky pains due to temporary obstruction of the appendix lumen, with conse- quent distention, which subsides, leaving no trace behind. As a general thing, however, some form of inflammation is associated with pain in this region, and such inflammations may vary in degree within the widest bounds. We may have a simple catarrh of the mucous mem- brane, with a reddened and swollen mucosa and an abundant secretion. With this there will be found an infiltration of small round-cells into both the mucosa and the submucosa, with swelling of the follicles. An appendix so affected appears thicker and stiffcr than normal. There is probably almost always some obstruction to the outlet from this cause, so that the appendix becomes distended with mucus and fecal matter. These are the cases w^hich subside and recur without marked and per- manent damage to structure, though there maj' be erosions and conse- quent cicatrices if the process is frequently repeated. Obviously, such cicatrices encourage subsequent attacks, while one occasional result of such attacks is a cicatrix, which, by its contraction, produces a complete stenosis. In such cases the appendix is transformed into a retention cyst. The contained fluid may be sterile apparentlj^, and the C3'st may remain for a long period, without other result than pain and occasional functional disturbance. On the other hand, the retained fluid may become septic — a more usual result, so that you wdll find a purulent fluid within the appendix associated with thinning and destruc- tive changes in the walls. Such a condition may be likened to empyema of the gall-bladder. Rarely, the cystic tumor may grow to a consider- able size, even as large as the closed fist. Such are the conditions known as " catarrhal appendicitis" and " suppurative appendicitis " ; but we are coming to believe that they are less common than was supposed at one time, or more properly that they do not often remain innocent, buf develop into more alarming forms of the disease. FORMS OF APPEXDICITIS 23 FORMS OF APPENDICITIS Acute appendicitis, often perforative, is the grave and urgent con- dition which is commonly meant when we speak of appendicitis. It ma}' come on suddenly, without previous warning, or it may develop out of a previous and more chronic condition. There are the swelling and obstruction precedent; the mucosa and the deeper tissues become infiltrated; slight hemorrhages and erosions occur; bacteria find their way into the tissues; the appendix becomes enlarged and stiffened; active ulceration of the mucosa may supervene, and perforation may quickly follow at any point from the tip to the base. If this were all, the condition would be found uniform, and the S3'mptoms in various cases not dissimilar, but the student must remember that the appendix is a movable organ, covered with peritoneum, and placed variously in its relations to the cecum and other abdominal viscera. The rate of progress of the infection is also a variable quantitj-. If the process be delaj'ed and the organisms few and not markedly virulent, the case may run a subacute and prolonged course. As the inflammation extends through the coats of the organ an injection of the serosa takes place; mdeed, that is a frequent and earty event, and fibrous adhesions quickly are set up. In the great majority of cases such adhesions are formed — this is nature's protective process. The appendix becomes glued to the surrounding tissues and organs. Frequently one finds it wrapped up in the omentum, which presents a strong barrier to the progress of a dangerous infection. Along with the inflammation of the wall of the appendix there is a progressive suppurative thrombosis of the appendix vessels, with destruction of tissue, thus establishing a vicious circle, the progress of the primary inflammation affecting the vessels, the affected vessels in their turn failing to nourish the tissues, and conse- quently a rapidly spreading necrosis or gangrene. It is not necessary that the perforation be macroscopic or even microscopic in order to act upon the serosa, for infecting material may reach the surface without actually breaking down in necrosis the intervening tissues. However that may be, with involvement of serosa and neighboring structures the progress of the disease may go on in a variety of ways. The infec- tion of the adhesions about the appendix may spread, involving organs more and more remote, until a great " cake " or matted mass of viscera results. In such cases suppuration usually supervenes, and pus collects in pockets about the appendix, the omentum, and among the coils of intestines. The destructive process in the appendix may not cease with the escape of infecting contents into the surrounding tissues, but the necrosis may continue until the organ is destroyed or sloughed off, leavmg a mere hole or stump in the cecum to mark its site. Sometimes several sections of the appendix are found scattered about and adherent through the mesentery and omentum. If unchecked, the extension of suppuration may be remarkable. Great lakes and wells of pus interspersed among matted intestines may fill the lower part of the abdomen and pelvis ; sometimes the intestines 24 THE ABDOMEN themselves are involved in necrotic changes. In a recent case of two weeks' standing I found 4 feet of ileum detached from its necrotic mesentery and floating loosely in a lake of pus. In this case the appen- dix had disappeared and was represented only by a great hole in the cecum, from which poured a stream of feces. In the case of infections of the appendix, whether or not there be pus present, — and there is always a purulent-looking fluid, — one hopes that the process will remain limited and will not invade the general peritoneal cavity. That chance of such an invasion and the consequent great danger to life are possible ; but so long as diffuse peritonitis has not oc- curred, the chance of cure is considerable. Let us consider for a moment what may be the outcome of a perforating api^endicitis if left to nature. There can be no doubt that in a considerable proportion of cases the acute process begins to subside after the fourth or fifth day. The abundant lymphatic connections of the peritoneum take up and cany off the infecting agents. For a while adhesions become more dense and Fig. 7. — Diagram showing segmented appendix. incarcerate the disease. Resolution takes place, reparative processes follow, and in the course of a few weeks nothing is left to mark the seat of trouble save a few adhesions and a crippled, distorted appendix. Even when pus is present, it may be strongly confined; small amounts may be absorbed, and large amounts may find exit either by rupture into the intestines, bladder, or vagina, or may work their way through to the skin and ''point" externally. This tendency of pus from appendicitis to burrow in sundry directions following the line of least resistance has given rise to diverse and pvizzling symptoms and signs. We see ab- scesses pointing in either inguinal region, burrowing under the cecum, liver, and diaphragm, and breaking into the lungs and bronchi, followed by the expectoration of pus. Pus from the appendix has been vomited and has been passed by urethra and rectum. I have seen an appendix abscess pointing in the prevesical space, and it is not uncommon to have the abscess open in the lumbar region. Such abscesses and burrowings of pus as I have described are due to FORMS OF APPENDICITIS 2'5 the course of the disease being limited and directed by fibrinous adhe- sions, or to the appendix itself being jDlaccd in unusual positions — behind the cecum, under the liver, adherent to the bladder, etc. The conditions which we have been considering are the more common and are those least likely to become lethal, but there is a development of acute appendicitis which is far more grave — that form which involves the free peritoneal cavity, which spreads rapidly, and usually ends in death from peritonitis. Such a peritonitis may be due directly to a rapidly perforating appendicitis, which progresses without the formation of adhesions, or it may be due to the breaking-down of adhesions and to the invasion of the general peritoneal cavity by infective material from an abscess. We shall study general peritonitis in a subsequent chapter, There are other forms of appendicitis and other causes than those which I have mentioned. Appendicitis may be due to tuberculosis of the appendix, in which case it is usually associated with a general intesti- nal tuberculosis. Writers have reported appendicitis due to irritation by intestinal parasites. Moreover, one sees occasionally diseases simulating appendicitis, and the conditions may be confused with fecal impactions, gall-stone colics, renal colics, actinomycosis, and symptoms dependent upon visceral ptosis. Some years ago I reported a curious case in which all the symptoms of appendicitis appeared to be present; but upon opening the abdomen, I found the appendix normal, while a mass of dry and dense orange-pulp was discovered packing the caput cceci. Age has a decided bearing upon the liability to appendicitis, as one would expect from what we have heard of the developmental and obliter- ative changes in the appendix. The disease is most common between the ages of fifteen and thirty, and decreases in frequency after that time. Nevertheless, we are finding that appendicitis in children is frequent, and numerous writers have reported cases from the age of one year and upward;^ Sex, too, has been regarded as having a bearing upon liability to these inflammations, and probably men are affected more frequently than women; but the great series of statistics now at our disposal show that women are not infrequently affected, and some reporters have recorded more women than men in their lists. Sometimes it appears that there is a family predilection for appendicitis. We use the terms relapsing appendicitis and chronic appendi- citis— terms indicating conditions which merit serious study. From our discussion of the natural history of the disease it appears that attacks of acute appendicitis may subside and may recur. If the obliterative process does not destroy the organ, it leaves it in a condition favorable for subsequent attacks, and experience teaches that subsequent attacks are common — indeed, that is the usual history of our cases. The surgeon, on being called to see a case of acute appendicitis, frequently learns that this is not the first attack, but however that may be, the 1 See McCosh, Appendicitis in Children, Jour. Amer. Med. Assoc, September 24, 1904; and Beth Vincent, Boston Med. and Surg. Jour., October 1, 1908. 26 THE ABDOMEN condition found does not vary from those acute attacks already described. The propriety of the term chronic appendicitis has been questioned, and surgeons have asserted that such a disease does not exist, but that recurring or relapsing appendicitis is the proper term. On the contrary-, it appears that the term chronic appendicitis is a proper one, because definite chronic trains of symptoms are found in many cases, and such symptoms are associated with definite pathologic changes in and about the appendix. One finds injection and thickening of the whole organ, cicatrices, kinks, and adhesions, which, though unassociated with an active inflammatory process, do, by their constant presence, set up annoying or grave symptoms, while at any time these symptoms may be aggravated or rendered alarming by a supervening acute attack. An important practical reason for using the term chronic appendicitis is for the education of the community, and I urge students and prac- titioners, when discussing appendicitis with patients and their friends, to insist constantly upon the clinical distinction between acute appendicitis and chronic appendicitis. The community appreciates in a general way that operations for chronic appendicitis, or "between attacks," are far less grave than operations for acute appendicitis; nevertheless, the word "appendicitis" and the word "operation" are sounds of dread. The whole subject is terrifying, and often needlessly so. SYMPTOMS OF APPENDICITIS As for the symptoms of appendicitis, it is well to divide the subject into several headings: 1. Symptoms of acute appendicitis when the inflammation is still confined to the aiDpendix. 2. Symptoms of acute appendicitis which has perforated and involved neighboring structures — periappendicular tumor and abscess formation. 3. Appendicitis caus- ing diffuse peritonitis and other complications. 4. Symptoms of chronic appendicitis. The first, most important, and omnipresent sj'mptom of acute appendicitis is pain — often agonizing pain. In his important review of 2000 cases Murphy states that "pain is a constant and uniform symptom, and was not absent as an initial symptom in this series of 2000 cases. "^ This initial pain rarely is definitely localized. It may be general over the abdomen. Frequently it is referred to the epigas- trium. Often the patient holds himself rigid and dreads palpation. Such disseminated pain is reflex, for we recall that the nervous mechan- ism of the appendix is shared with the stomach and small intestine. The initial pain is due to obstruction and distention of the lumen of the appendix. While the pain is present, one may feel confident that the disease is still strictly within the appendix. This severe pain is usually transient, and reaches its height in about four hours from its onset; by that time it becomes localized in the right iliac fossa; after this it subsides gradually, if all goes well, for the exudate is absorbed, or 1 John B. Murphy, Amer. Jour. Med. Sci., August, 1904. SYMPTOMS OF APPENDICITIS 27 slowly released into the cecum, and by the end of thirty-six hours the pain may have subsided entirel}-, in which case one may regard the attack as over and may look for convalescence. Probably 75 per cent. of the attacks of appendicitis are of this nature and run this course to spontaneous recovery. However, if within thirty-six hours pain is relieved suddenly — that is a danger-signal. It may mean escape into the cecum of an obstructing body, but more often it means perforation — rupture of the appendix or complete gangrene of that organ. Nausea and vomiting follow pain in acute appendicitis. If they precede pain, one questions the diagnosis of appendicitis and looks for some such condition as acute gastritis. The nausea and vomiting in acute appendicitis are reflex also. The primary nausea usually subsides shortly. Tenderness in the region of the appendix practically always is pres- ent in acute attacks. Usually it is somewhat diffuse, but often it is located at a definite point — sometimes at the umbilicus, but more com- monly at what is known as McBurney's point — in a line drawn between the anterior-superior spine of the ilium and the umbilicus, about 1^ inches from the anterior spine. ^ Other symptoms and signs are a flushed and anxious face; slight general distention of the abdomen; the right thigh held flexed so as to relax the iliopsoas muscle, which underlies the appendix; a moderate elevation of temperature, sometimes preceded by a chill, and a variable pulse, ranging between 80 and 100. The condition of the bowels is not particularly significant : usually there is constipation. During this acute attack careful palpation will elicit not only tenderness, but often the enlarged appendix, which may be easily palpable in thin subjects. It is my habit, if the patient is seen early and the condition is obscure, gently to pass my hands, previously wet in warm water, over the whole abdomen. The greater part of this surface may be handled with com- parative freedom, but upon approaching the right iliac fossa resistance and discomfort pointing to a local trouble are experienced by the patient. Another useful maneuver is slightly to irritate the skin b}"- gently pinch- ing the surface of the abdomen, when the skin in the appendix region is found more sensitive than that elsew^here. An important feature of the examination, never to be neglected, is exploration of the rectum. Very often the patient, when thus exam- ined, will experience a sensation of sharp localized pain high in the rectum, even though the finger discover nothing abnormal. You must satisfy yourself that the expression of pain is not clue to alarm or to the discomfort of a stretched sphincter. In the early stages of appendicitis the range of pulse and tempera- ture is of little significance, though a mounting pulse means more than does a high temperature. At this early time also the leukocj^te count has little bearing on the situation. It is usually slightly elevated — • 10,000, 12,000, or even 15,000 "whites"; but it is significant only when 1 For an interesting discussion of McBurney's and (Robert T.) Morris's points see Jour. Amer. Med. Assoc, January 25, 1908, p. 278. 28 THE ABDOMEN mounting steadily and associated with other symptoms and signs. A sudden drop of the temperature to normal, especially when associated with a rise of pulse, means trouble, and indicates probable perforation of the appendix, with a temporary cessation of septic absorption. If all goes well and the inflammation subsides, convalescence may be short and the jiatient ma}- regard himself as sound again in the course of a few days or of a week at the most; but the physician must bear in mind the probability of a subsequent attack, and must take his measures and warn his patient accordingly. Appendicitis with Periappendicular Involvement. — In a con- siderable number of cases, and these are the ones which try the nerves and call for the best surgical judgment, appendicitis does not subside quickly, but progresses to the involvement of other structures. After the initial disturbance which I have described the pain may decrease in a measure, tenderness may be somewhat less acute, nausea may cease, and pulse and temperature may show a slight drop; but convalescence does not proceed. Pain remains localized in the right iliac fossa; slight nausea may persist, as well as abdominal distention; obstinate constipa- tion ensues. Gradually the temperature may rise in a somewhat typhoidal fashion. The pulse mounts to 100, 110, 120, and higher. Leukocytosis increases. Frequently, vomiting may supervene. A mass may become evident in the appendix region — at first obscure and perhaps covered b}' distended bowel; later, more clearly diffused, generally resistant, rarely fluctuant, definitely outlined, exquisitely tender. The finger in the rectum may encounter boggy tissues or dis- tinct fluctuation. The right side of the abdomen is held rigid, and it may be almost board-like, while on slightly irritating the skin a charac- teristic spasm of the right rectus is seen; localized edema of the skin appears. Sometimes the tenderness reaches into the flank, and, if the appendix be retrocecal, acute tenderness and fullness even may be found in the lumbar region. These signs and symptoms indicate a progressive infection, an in- volvement of the peritoneum with a serous, a serofibrinous, or fibrino- purulent exudate. Happily, adhesions are forming, a matting of intes- tines and omentum is taking place, and pus is collecting in the inter- stices. In such cases again one may not foretell the outcome; but the conditions present have already been described sufficiently in our con- sideration of the pathologic anatomy. Termination in Diffuse Peritonitis and Other Complications. — If resolution does not take place, the clinical picture becomes more and more alarming; the patient's face continues flushed and anxious; frequent persistent vomiting ensues, with straining and retching: there is absolute constipation; the temperature continues high, with slight, if any, remissions ; the pulse is full and rapid ; the leukocyte count may drop at first, and later may rise to 30,000, 40,000, or more; the whole abdomen becomes rigid ; its distention increases ; it is every^where tender, especially in the appendix region; the normal ballooning of the rectum may become obliterated; the urine is high colored, often loaded with albumin and SYMPTOMS OF APPENDICITIS 29 casts, and is passed in small amounts; the normal sounds of peristalsis cannot be heard with the stethoscope; Peters, a Canadian writer, has called attention to the "telephonic properties of the inflamed abdomen in peritonitis" — the distended coils of intestine pressing against the diajihragm transmit the heart-sounds, so that they may often be heard low do^^•n in the abdomen.^ I have often found this sign striking and significant. The vomit, at first bile-stained, becomes more and more offensive as intestinal contents are returned into the stomach.^ Such is the picture of an intense diffuse peritonitis resulting from appendicitis. Even though peritonitis does not supervene, other grave complica- tions may ensue, resulting in pyemia. Abscesses may make their way in various directions, as has been pointed out, and there are those rare cases of the rupture of an abscess into a vein, producing suppurative thrombosis. Sometimes an abscess may become surrounded by a mass of cicatricial tissue, so that the condition suggests actinomycosis; but the general condition of such patients rapidly deteriorates, and the symptoms are more grave than commonly is seen in a localized actino- mycosis. The nature of the infecting organisms in acute appendicitis seems to have a bearing upon the progress of the disease and upon the clinical picture. If staphylococci be the offenders, the resulting exudate checks immediate systemic absorption of poison, and protects the patient against an overdose of the septic products. "When the exudate loosens, rapid absorption and sudden collapse, with diarrhea and an anxious expression, soon followed by death, are apt to occur. If we are dealing with streptococci and their invasion of the peritoneum, there ensue rapid blistering of that membrane, a high pulse, and active delirium; and, on the other hand, the colon bacillus may produce but slight local irritation and a moderate fever. The progress of the coli commune infection is slow, generalh\ In infection by staphylococci there is little pus in the peritoneal cavity usually, but when there is a large amount, it is of the seropurulent t3'pe. In the case of streptococci there is little if an}- free pus, but the peritoneum has a peculiar dry, granulated, blistered ap- pearance. Colon bacilli produce a copious, offensive pus, thick and creamj'. The profound collapse which is seen in the cases of diffuse peritoni- tis does not mean recent perforation, but indicates advancing septic absorption, and occurs late in the course of the disease. The symptoms of w^hat is called chronic appendicitis are more elusive than are those of acute appendicitis, but we are coming to recognize the condition as far more common than was supposed at one time. You must note the distinction between chronic appendicitis and relapsing appendicitis, in the sense in which we are coming to use the terms. Relapsing appendicitis signifies a series of acute attacks of appendicitis following one another at var3'ing intervals, while each 1 Canadian Jour. Med. and Surg., December, 1902, p. 420. 2 So-called "fecal vomitus" is usually the secretion of the small intestine mixed with altered blood. 30 THE ABDOMEN attack may bo grave. The liability to nH-unvnce in acute appendicitis has long been recognized, and writers estimate variously that liability, Fitz placing it at 44 per cent, of all cases; Hawkins, at 23.0 per cent., and other writers as high even as 60 per cent. By chronic appendicitis I mean a condition which is not necessarily associated with acute attacks. A case from my list will illustrate what is meant. Some years ago there came under my care a college student, twenty-one years of age. He was a robust, well-developed, athletic young fellow, a foot-ball player, of excellent habits and wholesome mode of life. Three years before I saw him he was supposed by his physician to have contracted malaria. Every six or eight weeks he had, for four or five days, attacks of malaise, with headache, slight pyrexia, occasional nausea, and general al^xloniinal discomfort. Betw^een these attacks he regarded himself as well, but he confessed to a delicacy of digestion — hearty meals distressed him — and an irregularity of the bowels, with alternating periods of constipa- tion and diarrhea. These conditions had continued without special change. The young man had sought various advice; had traveled in search of health, and had lived in sundry places. Finally, during one of his remissions he happened to consult me, when, on making a careful abdominal examination, I made out repeatedly a sensitive, not painful, point in the right iliac fossa. Convinced that his appendix was at fault, even if it was not the source of the trouble, I removed it. The patient's recovery of health was prompt and permanent. Such an example is not typical of all cases of chronic ai)pendicitis, but it suggests the sort of cases we are discussing. In general terms patients with chronic appendicitis complain of more or less dyspepsia and general poor health, without very definite symptoms except that the disturbance is abdominal. Rarely do they give a history of an acute attack of appendicitis. Acute attacks are more likely to be followed by acute attacks. The chronic condition is found frecjuently in chiklren, as well as in adults, and accumulating experience has convinced us that the group chronic appendicitis is far larger than most physicians and the writers of text-books are disposed to think. DIAGNOSIS OF APPENDICITIS In the diagnosis sundry conditions simulating appendicitis must be borne in mind. Whenever confronted with a case of abdominal disease, try first to rule out appendicitis. A common and serious error is the confounding a perforating duodenal or gastric ulcer with appendicitis. A duodenal ulcer breaks through into the abdominal cavity, pouring out intestinal contents into the right flank, over the kidney, and dovm into the appendix region. Symptoms suggestive of appendicitis may arise immediately. Whichever condition is present, however, prompt operation is indicated, so that in the hands of an intelligent surgeon no time is lost. Typhoid fever has been mistaken for appendi- citis, and often the differentiation is difficult. In many cases of appendi- citis one must bear in mind the symptoms of typhoid, especially the TREATMENT OF APPENDICITIS 31 character of the temperature and stools, the prodromata, the gradual onset, the enlarged spleen, the rose spots, and the reaction to Widal's test. Rarely, a tj-phoid ulcer may be located in the appendix, and writers estimate that about 5 per cent, of all typhoid perforations are appendiceal. Then there are actinomycosis and tuberculosis — chronic processes, but sometimes impossible to determine before operation. Other diseases — inflammation of the gall-bladder and ducts, renal calculus, mesenteric thrombosis, inflammation of a Meckel's diverticu- lum, cancer, inguinal adenitis, intestinal obstruction from fecal impac- tion— all must be remembered, and usually are easily distinguished, with the exception of mesenteric thrombosis and disease of Meckel's diver- ticulum. In women, too, we must think of diseases of the right ovary and tube. When we see a patient who gives the history of sudden, prostrating abdominal pain, nausea and vomiting, with constipation, with disten- tion, with right-sided rigidity, with high rectal tenderness, spasm of the right rectus, tenderness in the right iliac fossa, a rising temperature and pulse, and a leukocytosis of 10,000 and upward, we are safe in con- cluding that here is a case of acute appendicitis, though we must remem- ber always that all these symptoms are not constantlj^ present in that disease. Above all things, never forget that an obscure, obstinate, and acute abdominal distemper, suggestive of sundry diverse diseases, is appendicitis on the chances, and in a great majority of cases. A discussion of the prognosis of appendicitis is profitless, because of the varying types of the disease, and because, more than any other surgical lesion, appendicitis lends itself to surgical treatment. We have seen that a majority of acute cases recover spontaneously, though a large proportion of them are subject to relapses, and no man may say which will relapse and which will remain well. TREATMENT OF APPENDICITIS The treatment of acute appendicitis has been made a subject of infinite variety. It should be almost a matter of routine. Like the offending eye in the parable, the inflamed appendix should be cut out and cast away. Yet so various are the symptoms of appendicitis, so confusing often are they, and so manifold are men's points of view, that it seems as though this discussion of treatment may be prolonged through the ages. In many cases patients recover spontaneously. That is the hub of the situation; and because many cases recover spontaneously, therefore certain men say, "any case may recover spontaneously, so let us wait." In contracHstinction to this opinion, which recognizes an immediate mortality of at least 20 per cent., it is weU to balance the fact that if we operate upon all cases of appendicitis, we shaU have a mortahty of 5 per cent.^ Divergence of opinion on this matter is more accentuated now than it was twenty years ago. Twenty years ago a 1 John B. Deaver, Factors in the Mortality of Appendicitis, Jour. Amer. Med. Assoc, September 24, 1904. 32 THE ABDOMEN large majority of physicians and surgeons believed that we should delay operation, should wait until an abscess was '' ripe/' and should then open it under the most favorable conditions. This was called the conserva- tive method, and ph}'sicians were wont to watch the case until, in their opinion, it was time for operation, when they called the surgeon. Grad- ually, the scales have been reversed. No sane practitioner now regards appendicitis as a "medical disease" to which a surgeon occasionally may be called. It is a surgical disease as much as is a br-oken leg, and the surgeon should be calletl as soon as appendicitis is suspected. The practitioner must not wait to make the diagnosis. He must call the surgeon to do that. He must call the surgeon to determine the cause of every acute abdominal pain such as I have described in this chapter. As a knowledge of appendicitis developed we came to see that opera- tive measures must be applied early and thoroughly ; but there has always been a certain number of men who opposed this view. Numerous modes of treatment have found favor, among the advocates of delay, such methods as the use of opium and ice, on the one hand, of saline purges and poultices, on the other. Happily, such treatment is now relegated by the best practice to the limbo of a contemptuous oblivion; but in spite of strenuous years of missionary work, we find bad practices still pursued in many communities. Setting aside a consideration of antiquated and improper procedures, we find that there is still a division of opinion among competent surgeons as to the wisdom of operating always and in early stages of acute appendicitis. There is still debate upon the question whether or not to operate at once in the second stage of appendicitis — in that stage when periappendiceal tissues are beginning to be involved, and when adhesions of strength sufficient to confine the process have not yet been formed. In the vast majority of cases, how- ever, all competent surgeons are agreed that immediate operation is necessary. Let us now consider briefly the early operation. We have seen how appendicitis usually starts; how, commonly, the process is at first confined to the appendix, and we know that no man may say at the outset what the course of the disease will be. Therefore, at the outset, open the abdomen and remove the appendix — and we understand by outset, within the first twenty-four or thirt3"-six hours. Early Appendectomy. — There are two excellent methods, among others, of reaching the appendix — the McBurney method and the retromuscular, sometimes called Battle's method. The McBumey method was devised by that surgeon some sixteen years ago.^ Its purpose is a muscle-splitting, not a cutting, operation, so that practically structures are not damaged, and, especially, nerves and aponeuroses remain intact.^ The skin is incised obliquely for 3 or 4 inches, over the usual seat of the appendix. The aponeurosis of the external 1 Ann. Surg., 1894, vol. xx, p. 38. 2 When possible, employ the McBurney method below, or on a level with, the anterior iliac spine. The lower tlie opening, the wider and freer can it be made. This low opening, "the low McBurney," is my operation of choice in all appendix operations. TREATMENT OF APPENDICITIS 33 oblique is reached and split longitudinally. The parts are drawn aside with narrow retractors, exposing the internal oblique, running at an angle with the previous incision. In its turn this is split, and the underlying trunsversalis is treated in the same fashion. Then the peritoneum is opened, the finger is introduced, and the cecum is drawn to the surface. In A-S4. X 1 TRAriSVCKifiLtd Fig. 8. — McBurney's operation (high). Battle's method the abdomen is opened through the sheath of the rectus. The uncut rectus is drawn inward, and the peritoneum behind it is incised. In closing the wound the muscle falls back into place without stitching. The peritoneum and anterior sheath alone are sutured. These maneuvers are facilitated by tipping the patient into the Trendel- Fig. 9. — McBurney's operation (low). enburg position — that is, inverting the body so that the pelvis lies at an angle of from 30 to 45 degrees above the shoulders. The cecum is drawn outside the wound, and the appendix is delivered. Usually it is easy at this stage to find the appendix, for it is swollen and readily palpable and pops out at once. If it is not quickly discovered, the best guides to it are the longitudinal bands of the cecum, which converge 3 34 THE ABDOMEN at the appendix immediately below and behind the ileocecal valve.* Remove the appendix by clamp, ligature, and cautery, as follows: Compress the organ close to the cecum with a stout pair of hemostats; then remove the hemostats and apply firmly a stout catgut ligature in the crushed line. Clean away toward the tip of the appendix the con- tained fluid for a short distance from the ligature, and again grasp the Fig. 10. — McBurney's operation (low). appendix with hemostats about J inch from the ligature. Cut away with the actual cautery the appendix, between the ligature and the hemostats.^ Drop back into the abdomen the cecum with the appendix stump, and follow it down with a gauze wick which must be left in place as a drain. Do not leave the stump undrained, and do not sew up the wound. I believe sewing up to be a dangerous procedure; nothing -^9?, Fig. 11. — Diagram showing delivery of cecum. is gained in time or strength of scar by so doing, and no man may say that a nidus of infection does not remain which, if left undrained, will lead to disastrous results. If all goes well with the drained case, the wick may be removed at the end of forty-eight hours, the tissues will fall together, the external oblique aponeurosis and the skin may be ^ Note Hough's peritoneal band, running from the anterior iliac spine to the cecum at the base of the appendix. 2 I shall mention later the debated question of treatment of the appendix stump. TREATMENT OF APPENDICITIS 35 stitched if one chooses, and convalescence will progress without disturb- ance and without resulting hernia. In the after-treatment of these early cases three factors are to be ob- served : rest, feeding, care of the bowels. The patient should be kept in bed for at least twelve days ; he should then begin to sit up a little every day, and by the end of three weeks he should be walking about. He should wear a stout abdominal binder for a month after the operation. This relieves occasional discomfort and provides support to facilitate the firm healing of the scar. In most cases, after two months, patients may turn to active exercise. For the first twenty-four hours after the opera- tion the patient should be starved, and allowed water only. For the second twenty-four hours he may have clear soups and broths. After that a gradually increasing diet, until, at the end of five days, he is eating regularly. The care of the bowels is a debated question. They might be left alone, waiting upon nature's prompting, except for a ten- dency to meteorism, sometimes associated with severe pain. One should remember, however, that most of these patients are emergency cases and come to the operating table with bowels more or less loaded. My practice, therefore, is to give the patient a high glycerin enema twenty- four hours after the operation, and at the end of thirty-six hours to clean out the bowels from above with calomel and salines.^ This practice is not invariable. In many cases it must be altered; when distention and pain are marked, high enemata and the rectal tube may be used soon after the recovery from ether. Furthermore, it is sometimes advisable to employ calomel immediately on the subsidence of ether nausea. The reader will see that such dealing with acute appendicitis in the early stage does not differ materially from our treatment of the appendix "in the interval," as I shall explain later. Discussion rages about the question of operating upon cases in which the inflammation has spread beyond the appendix. The weight of authority directs that we operate at once even in this stage. Objections to such operating have been urged by certain well-known writers, dealing with certain stages of periappendicular inflammations, and their sentiments found able voice through A. J. Ochsner at the Saratoga meeting of the American Medical Association in 1904.^ He pointed out that the mortality in appendicitis results from the extension of infection from the appendix to the peritoneum, or from metastatic infection from the same source; that the distribution of the infection is accompHshed by the peristaltic actions of the small intestines, and that it is also accomplished by operation after the infectious material has extended beyond the appendix, and before it has become circumscribed. Accord- ingly, in certain of these cases it is advised that operation be delayed until strong adhesions are formed, and in general terms the time limit for such delay is from thirty-six hours from the onset of the disease until 1 Calomel, \ grain every hour for four doses; a Seidlitz powder one-half hour after the last dose of calomel, and a low suds enema when the desire for a movement is felt. 2 Ochsner made a first detailed statement at the meeting of the American Medical Association in 1903. See Jour. Amer. Med. Assoc. 36 THE ABDOMEN about the fifth day or later, if the process is obviously subsiding. To accomplish rest and to give nature an opportunity to wall off the disease it is directed that every form of nourishment and cathartics by mouth be prohibited, and that gastric lavage be employed in oi'der to remove any food or mucus from the stomach. Nutrition is to be maintained by low enemata. Large and high enemata must not be given. It is claimed, and apparently is proved by a great array of figures, that in this way cases of acute a])pendicitis may be changed into relatively harmless cases of chronic appendicitis, and that the mortality may be greatly reduced. In spite of vigorous criticism by a majority of surgeons, and skepticism as to such results, there is no doubt that the treatment above described, which has come to be known as the "Ochsner treatment," has been remarkably successful in the hands of its author. Surgeons claim, however, — and with this view I am in heartj^ sympathy, — that this let-alone treatment is dangerous in the hands of the general practi- tioner who attempts to carry it out without consulting a surgeon. The disease is so insidious, its changes, progress, and recessions are so rapid, complicated, and puzzling, that it is far safer to consign all cases imme- diately to the hands of an experienced operator. If his experience shall prompt him to delay, it wdll also prompt him to operate, should prolonged delay appear dangerous. Though the Ochsner figures show a low mortality and a brilliant series of results, so, too, do the figures of competent surgeons who operate at once in practically all cases. J. B. Deaver is a strenuous advocate of immediate operation,^ and his statis- tics, showing a mortality of 5 per cent, only, can hardly be improved upon. If the operation be properly done, if the spreading infection be walled off, if prolonged effort be not made by the surgeon when searching for the appendix, if pockets of pus be sought out and drained, the results will be favorable in a vast majority of cases. There are, however, certain conditions under which all men are agreed i;hat operation should not be attempted; it may be impossible to secure a competent surgeon for the given case, or there may be some serious underlying disease, such as advanced nephritis, heart disease, diabetes, or tuberculosis. Operation is ill advised also in those cases of diffuse peritonitis in which the abdomen is distended, the temperature high, the pulse rapid and of high tension, the patient's expn^ssion anxious and indicative of serious intra-abdominal infection, the bowels consti- pated and unable to cause the expulsion of flatus, and in which vomiting is continuous and tenderness is diffuse over the entire abdominal wall. Then the tongue is dry and brown, the skin is dry, and the frequent delirium is shortly followed by coma and death. "In another class of cases the features are pinched, the skin cold and clammy, the temperature is normal or subnormal, the pulse rapid and thready, the leukocytes are below normal in numlier, and the abdomen hard and rigid throughout, without much distention. "- Such conditions as the above are desperate. Diffuse and rapidly 1 J. B. Deaver, Factors in the Mortality of Appendicitis, Jour. Amer. Med. Assoc, September 24, 1904. 2 Deaver, ibid. TREATMENT OF APPENDICITIS 37 spreading peritonitis is present, and the patient is on the brink of dis- solution. Operation, then, is practically always followed by death. If it does seem best to operate, however, in order to relieve distention or in the hope possibly of draining septic products, one should be satisfied with making an incision and inserting a large drainage-tube without irrigation and without sponging or manipulation of the tissues. One sees from the above statements that it is often impossible clinically to determine the time at which operation is wise or unwise in an advancing infection. Practically, the answer to the question amounts to this, that so long as the patient's general condition is fair and the toxemia is not extreme, some form of operation is indicated, whereas in the face of a profound toxemia, operation must be futile except for the relief of distention. If the stage favorable for operation has not yet been passed, one should remove the appendix, if accessible, as well as institute drainage. Observe that in discussing the advance of periappendicular inflam- mations I have not drawn a sharp line of distinction between the early progress of the disease and advanced diffuse peritonitis. I have not drawn this line because frequently it is impossible to differentiate, and because one may find within the abdomen unexpected conditions, quite different from those anticipated — sometimes a limited inflamma- tion, when a diffuse peritonitis was anticipated, sometimes an unex- pected spreading peritonitis. Under all circumstances the surgeon must be guided by his estimate of the patient's general condition and capacity for resisting infection. Happily, it occurs that in the great majority of cases adhesions do form, so that the progress of the disease is checked or retarded, and a localized inflammation surrounded by sound viscera is presented to the operator. The method of dealing with a localized process— inflammatory adhesions, exudate, pus-pockets, and necrosis — is as follows: Open the abdomen through a free incision somewhere to the inner side of the inflamed mass — a low McBurney incision is recommended; the cut should be long enough — five, six, or more inches— to admit of free manipulation within the abdomen;^ recognize by gentle intra-abdominal palpation the limits of the mass, and wall it off with gauze wicks before proceeding (Fig. 12). Such gauze wicks carefully and deftly introduced into the pelvis, to the inner side of the mass and above it, limit the possible damage from escaping septic material. Having walled off the intestines, one may proceed at leisure. Break up adhesions to the outer side of the mass, explore and evacuate pus- pockets, seek and remove the appendix, employing catgut figature and cautery; wipe out the wound carefully with gauze, and complete the operation by appropriate drainage — one wick to the appendix stump, 1 John G. Sheldon, A Posterior Incision in Certain Appendix Operations, Ann. Surg., September, 1904, p. 376. Sheldon has approached the disease by a lumbar incision, through the triangle of Petit. Sheldon has operated thus on about 60 cases, and claims for his method the advantage of perfect drainage and no chance of hernia. 38 THE ABDOMEN and, if conditions indicate it, two, three, or more wicks for walling-off purposes and for the drainage of separate pus-pockets. If the appendix has sloughed off and the cecum is open, drain by a tube the cecum at once, as in the operation of enterostomy, thus estabUshing a tem})orar)' fecal fistula and guiding intestinal contents away from the deep tissues. The tube (Fig. 13) ma}- be withdrawn in a few days, after which the fistula usually will close spontaneously. In the after-treatment of these wide appendicitis wounds far more care and attention to detail are demanded than after the simple early operation. In the compli- Fig. 12. — Appendix under cecum; pregnant uterus. Note walling off with gauze. Gated cases the abdominal wall must not be stitched up closely, though two or three through-and-through stitches at the ends of the wound are allowable; a large opening must be left for free drainage. For the first day or two exudate escapes copiously; gradually the amount diminishes, and gradually the wicks loosen. B}- the end of five days or a week the wicks may be withdrawn easily, and shorter, fresh ones substituted. Do not draw the wicks out roughly so long as they remain adherent to the viscera. Commonly, the wicks are all out and the wound granulat- ing superficially at the end of three or four weeks. A weak scar results, TREATMENT OF APPENDICITIS 39 sometimes subject to hernia, of which the patient must be warned; and sometimes a subsequent operation for hernia is necessary. The reg'uUition of the bowels and of the diet does not differ materially from that already described; but in these cases, with large wounds, con- valescence is slow, many weeks often are necessary for recuperation, and the use of an abdominal belt for five or six months may be im- portant. So far as concerns operating in cases of diffuse and spreading peri- tonitis from appendicitis, I do not recommend the multiple incisions, the wijDing and long-continued washing sometimes advocated. Open the Fie;. 13. — Mixter tube in cecum. abdomen by a free incision on the right, as already described, secure the appendix if it is easily accessible only, introduce into the pelvis a large fenestrated cigaret drain or split rubber tube, and provide for further tube-drainage through a stab-wound above the left inguinal ring.^ To relieve excessive and paralyzing intestinal distention puncture the bowel in several places with a trocar, and draw off gas and Hquid contents. I have seen no benefit from introducing concentrated epsom salts through the trocar, as is sometimes advised. The after-treatment is important, and the practitioner will do well to follow for a day or two the so-called Ochsner method — no food or drink 1 See an interesting discussion of this question by Lucius W. Hotchkiss in Med. News, July 2, 1904. 40 THE ABDOMEN by mouth, gastric lavage if vomiting persists, nutrient enemata, and the use of copious saline injections, preferably by the "seeping method" suggested by J. B. Murphy.^ In both diffuse peritonitis and in the simpler circumscribed cases the semi-u})right posture of Fowler is valu- able for promoting drainage and limiting the spread of infection. There are numerous other nice and complicated questions which arise in the discussion of appendicitis; but their consideration finds no place here except for two important points: (1) In the case of appendicitis occurring in pregnant women, one must disregard the pregnancy and operate. Miscarriage sometimes follows, but that is an inevitable risk. (2) When operating within the abdomen for some other lesion, always investigate the appendix, and remove it if it is involved, or if there is cause to suspect that it may become involved through the spread of a peritoneal inflammation antl the formation about it of adhesions. Operation for Relapsing and Chronic Appendicitis. — Kocher says that this operation has been treasured as the jewel of operative surgery. So easy is it, and so far reaching are its benefits, that the question often has been raised, should not the appendix be removed whenever the abdomen is opened for any purpose; and when one remem- bers that a majority of mankind, first and last, suffer in some degree from trouble in the appendix, this proposition does not sound unreason- able. After removal of the crippled, but c[uiescent, appendix, 94 per cent, of patients make a prompt and complete recovery, and the remain- ing 6 per cent., though occasionally troubled by painful adhesions and irritation about the wound, are freed entirely from the dread of a sub- sequent appendicitis. The mortality in these operations is practically nil. The technic of removing the quiescent appendix is essentially that of removing the appendix in the first hours of inflammation, though in the case of the quiescent appendix the skin incision may be very small — from one to two inches in length. The approach may be made by either the high or low McBurney or the retromuscular (Battle's) route. I prefer the " low McBurney " because thus the opening may be enlarged without damage to structures. Having clamped and removed the ap- pendix, the question of the treatment of the stump has agitated sur- geons,^ but experience shows that sundry methods are safe and applic- able. Some operators cut off the undamped appendix close to the cecum and invert and stitch up the resulting hole ; some operators ligate and cut off the appendix and bury the stump by sutures in the wall of the cecum. For some years I have followed the practice of crushing and ligating the stump wath catgut, cauterizing the exposed end, burying it in the stump of the meso-appendix, and dropping it back 1 The method of allowing saline solution to seep into the rectum is widely ap- plicable in these cases, which demand a large supply of water for tlie exhausted tissues. A common vaginal nozzle attached to a fountain syringe is introduced within the sphincter ani. The reservoir is placed about 8 inches above the buttocks, and the solution, constantly kept warm, is allowed to drift through the tube. Many pints daily may thus be introduced without especial discomfort. 2 H. A. Kelly in Amer. Med., December 31, 1904, describes what he calls "the ideal method." TREATMENT OF APPENDICITIS 41 without further treatment. This method has been satisfactory in many hundreds of cases.* The httle wound in the abdominal wall may be secured with buried catgut stitches or with through-and-through sutures. It makes little difference so long as the severed aponeuroses are accurately repaired. The after-treatment differs in no essential from the after-treatment employed in the case of operations for early acute appendicitis. The patient sits up at the end of a week, is out of bed in ten days, and is about his business in from two to three weeks. No abdominal belt is worn, and no hernia results. The patient may indulge in violent exercise two months after the operation if all goes well. Appendicitis has been chosen as the subject of this first chapter because appendicitis is the most conspicuous example of acute abdominal disease. In the next chapter we shall advance upon a broader field, and consider the important surgical diseases of the intestines as a whole. 1 The rationale of this method has been admirably explained in a careful paper by M. G. Seelig, Ann. Surg., November, 1904, p. 710; and by H. Lilienthal in Med. News, November 28, 1903. Seelig's paper is so conclusive, and the large series of cases thus treated is so successful, that I unhesitatingly recommend this simplest of all methods. CHAPTER II THE SMALL INTESTINE AND COLON One of the most remarkable chapters in the history of medicine is that which tells of the development of our knowledge of diseases and injuries of the intestines. We are wont to think that the days of ancient surgery, which ended with Lister's explanation of the causes of wound infection, were hopeless da)^s for intra-abdominal surgery, and espe- cially for intestinal surgery. From our viewpoint they were hopeless daj'S so far as regards intelligent understanding of conditions and proper technic, but the old surgeons did not think them hopeless. The old surgeons often dealt boldly with intestines accidentally wounded, though they themselves rarely opened the belly to search for inward troubles. The draining and stitching up of intestinal wounds was not uncommon, and ancient literature is full of the discussion of such matters of technic. Here are two illuminating notes: In 1826 Denans* introduced silver rings into the lumen of the severed intestine, and clamped them together with springs, in a fashion suggesting the Murphy button, while Lembert, in the same year, described the extramucosa stitch, which still goes by his name.^ Lembert's and Denans' principles survive, and though we have improved on their measures during the past thirty years, it is interesting and humbling to reflect upon what they might have done had Lister lived before them. We must recognize the impossibility of distinguishing always disease of the intestines from associated disease of other organs, as well as from other accompanying and complicating diseases of the intestines them- selves. We see ptosis of the bowels combined with volvulus; hernia, with appendicitis; foreign bodies, with actinomycosis; and peritonitis, with them all. At the same time there are broader associations — calculi may perforate from the gall-bladder into the colon; appendicitis may be the remote cause of perigastric adhesions and distortions of the stomach, while malignant disease of any part may create its first incon- venience through metastases in a distant organ. In recent years writers have been insisting upon the association, with each other, of various lesions in the upper portion of the abdomen ; but such associations are not limited to the region above the umbilicus. All the abdominal organs, and organs beyond the abdomen even, fre- quently are closely and curiously associated in disease processes; for example, we sometimes see affections of the abdomen reflected in affections of the chest. ^ Recueil de la Societo Royale de Medecine de Marseilles, 1S26, I'an No. 1. - In South's edition of Chelius' Surgerj', vol. i, p. 465; see an interesting account of Shipton's success in repairing wounds in the intestines of dogs in 1702. 42 THE SMALL INTESTINE AND COLON 43 It is not proper, therefore, for the practitioner to study lesions as isolated entities — the method commonly employed. He must approach his patient with unbiased mind, and with a generous understanding of the delusion as well as of the significance of local symptoms — an under- standing favored and informed by experience of the operating-room and the postmortem table. Regarding misleading or obscure symp- toms, as I have said in another writing,^ the patient who complains of morning headache, of occasional eructations, of some palpitation, and of constipation may be the victim of gastric cicatrices and beginning pyloric stenosis. The man who tells you that he is troubled with distress several hours after taking food and with occasional stomach- ache may be suffering from gastrectasis or gall-stones. The child with a poor appetite, pallor, lassitude, and constipation alternating with diar- rhea may have a chronic appendicitis. The rather frail, neurasthenic young girl, or the tired mother of many children, the sufferer from dysmenorrhea, or the elderly widow with heartburn, may be affected with displacements of the stomach, the kidneys, or the uterus. With some appreciation, then, of the complicated mechanism with which we deal in approaching all disease, and particularly abdominal disease, let us study in detail the lesions of the intestines in particular. Regarding the anatomy of the bowels, we make one or two notes of importance: The duodenum is but partly covered by peritoneum; the jejunum and ileum are covered completely; and a portion only of the large intestine is covered completely — the sigmoid, the transverse colon, and sometimes the cecum. Portions of bowel but partly covered are bound down and fixed; portions completely covered by peritoneum swing at anchor, as it were; they are not grounded. The position of the cecum varies considerably : it may be high or low ; it may or may not be covered with peritoneum, and it may have a short mesentery. The position of the splenic flexure of the colon must not be forgotten. It is higher than the hepatic flexure, and has so sharp an angle that often it seems kinked almost, and as though contents would pass with difficulty. The transverse colon swings loosely below the stomach, and rises and falls with the movements of that organ. In operating through a small parietal opening upon the intestines, when a short loop of bowel is in view, one is constantly faced by the important question, With what portion of the gut are we dealing, and what is the direction of flow of its contents? Monks has con- tributed some valuable information on these points.^ There is no normal length for the small intestine in the adult. It is from 15 to 30 feet long. The upper 6 feet of intestine lie deeply in the left hypochondrium ; the middle portions usually occupy the center of the abdomen, while the lower portions generally are in the pelvis or in the right iliac fossa. The upper part of the gut is thicker than any other part, and normally is bright pink or red, the color gradually fading as we go down, and the vascularity becoming less marked. In the upper portion the valvulce 1 Surgical Aspects of Digestive Disorders, 1905, p. xi. 2 George H. Monks, Intestinal Localization, Ann. Surg., October, 1903. 44 THE ABDOMEN conniventes arc large and numerous, and can be felt always, or can be seen as i)inkish or whitish rings. The}- diminish gradual!}- in number, but especially in size as we pass downward, until about the middle portion, beyond which they can seldom be seen. The mesenteric vessels, opposite the upper portion of the bowel, below the duodenum, are dis- Intestinal localization (Monks). tinctly larger than elsewhere in the mesentery ; gradually they diminish as we pass downward until the lower third is reached, after which they retain the same size. Most interesting are the loops of the mesenteric vessels; opposite the upper portion there are primarj^ loops onh-, with an occasional secondary loop. As a rule, secondary loops become Fig. 15. — Intestinal localization (Monks). prominent at about the fourth foot from the duodenum. Going down further, secondary loops, and possibly tertiary loops, become more numerous and the primary loops smaller, the loops all the time approach- ing nearer and nearer to the gut. In the lower part of the mesentery the loops lose their characteristic appearance and are represented b}- a THI<] SMALL INTESTINE AND COLON 45 complicated network. The vasa recta are larger and better defined in the upper than in the lower portion of the bowel. The thickness of the mesentery varies with different subjects according to the deposition of fat; but, as a rule, it is thinnest in the upper portion of the track, and becomes thicker as we descend. In the upper portion there may be Fig. 16. — Intestinal localization (Monks). found small, translucent spots between the vasa recta. Monks calls these "lunettes," and finds that gradually they grow smaller, become streaked with fat, and disappear at about the eighth foot from the duode- num. To determine the direction of the fecal stream, observation of peristalsis is unreliable, because retroperistalsis may be present; but Fig. 17. — Intestinal localization (Monks). by passing the fingers down the side of the mesentery and its attach- ment, and by correcting any twist that may be present, then with a finger on either side the direction of the bowel may be observed. These studies of Monks' form one of the most valuable of such contributions to the surgery of the intestines. 46 THE ABDOMEN In Studying intestinal surgery bear in mind that there are three im- portant divisions of the subject: (a) The surgery of injuries; (b) of inflammations; (c) of new-growths; while at the same time one must II (Monks). remember constantly that lesions of the intestines often are secondary and complicate far-reaching constitutional disturbances. In consider- Fig. 19. — Intestinal localization (Monks). ing these three types of disease, remember that they all cause death in much the same way — through interference with metabolism, and in the end through peritonitis and toxemia. SYMPTOMS The examination for intestinal lesions is a difficult matter frequently, because the intestines are not always accessible by the methods employed in the examination of the more fixed abdominal organs. The patient's symptoms are an important guide: Pain suggests the location of trouble, but pain may be reflex or referred. The character of the discharge from the bowels is of value— frequent, loose, watery, bloody, lumpy, sHmy movements must be investigated, while the microscope and INTESTINAL OBSTRUCTION 47 chemical tests may throw further light on the problem. Constipation or complete obstipation suggests an obstruction somewhere; but we know that such conditions may mean merely the derangement of organs outside of and involving the intestines. In studying the signs, inspection is of value often. In a distended abdomen waves of peristalsis or retroperistalsis may be seen, and swellings or tumors occasionally may show themselves. Inspection of the rectum is sometimes useful when we are dealing with intestinal lesions, for ob- structions and sources of hemorrhage may be discovered there low down, while it is well, at the same time, to distend the sigmoid and colon with air or water, and then to determine their exact position when inflated, as well as their topographic relations to suspected disease. Palpation is the most important of our resources. Palpation elicits tenderness, detects resistance, and discovers tumors, masses, or fluc- tuating areas. Percussion discloses tympany, indicating a distended bowel; dulness or flatness shows impaction, obstruction, collections of fluid, or tumors. With a change of position of the patient shifting fluid, free in the abdominal cavity, is discovered by percussion. Aus- cultation is of value in determining the presence or absence of peristalsis, and in connection with transmitted heart-sounds (see p. 29) it may indicate a bowel paralyzed and distended with gas. INTESTINAL OBSTRUCTION The first and most conspicuous intestinal lesion with which the surgeon has to deal is obstruction of the intestines. This may be com- plete or partial. It may be acute or chronic, and it may be due to a variety of causes, many of which we shall consider later in detail, under their appropriate headings, such as volvulus, cancer, etc. Writers discuss sundry degrees of obstruction: stenosis, or narrowing; occlusion, or complete closure; stricture, due to disease of the wall of the intestine; constriction, due to pressure from without; strangulation, in which a strong irritation of the nerves in the intestinal wall occurs, and at the same time the circulation in the intestinal wall and mesentery is so affected that severe venous hyperemia, ending in gangrene many times, ensues. For our purpose it is not necessary now to consider elaborately all these forms, for we shall deal with them more or less in the discussion of special lesions. Generally, and in a broad sense, subject to certain exceptions, intestinal obstructions are associated with acute peritoneal inflamma- tions, on the one hand, or are free from immediate peritoneal involve- ment, on the other hand. And be it observed that the peritoneal in- volvements commonly are due to acute obstructions, while non-involve- ment of the peritoneum usually indicates chronic obstruction. A con- spicuous example of the first is the acute intestinal obstruction seen in strangulated hernia, causing "stoppage," with violent symptoms. An example of the second is seen in the case of cancer, slowly encroach- ing upon the lumen of the cecum, and shutting off gradually the fecal stream. 48 the abdomen' Acute Intestinal Obstruction Ileus is an ancient term ^vhi(■h is now used to indicate not a special patholose condylomata are due to in-itation from gonorrheal discharges. Considerable tumor masses foim, which may be mistaken for cancer, but the masses do not infilti-ate the skin. Histologically, they appear as papillomata. These condylomata may be excised safely and satisfactoril}'. Cancer of the anus is found in rare cases. Cancer here begins a good deal as does cancer of the lip. But cancer of the anus grows rapidly, in\-olYing the skin rather than the mucosa, often completely surrounding the anus. The inguinal glands and the glands about the ischiatic nerve are affected early. The only effective treatment is a wide and thorough excision, such as will be described in dealing with cancer of the rectum. Coming to tumors of the rectvun proper, we find that benign groidhs are not especially uncommon, and that these may be grouped in two classes — a con- nective-tissue group and an epithelial group. The former group is seen to de- velop in the muscular tissue of the rectum — fatty tumors, myomata, and fibromata. Angiomata have been reported, and one finds rarely echinococcus and dermoid cysts. All these tumors give rise to pain and constipation and may readily be dis- covered by digital or visual investigation. Frequently they may be removed with- out opening the rectal canal. Of the epithelial benign tumors, aden- oids or mucous polypi are the most com- mon. They develop in the lower third of the rectum, and may be harmless or may give rise to a trouble- some catarrh associated with tenesmus and hemorrhage. They are seen generally in children, but are often overlooked. They may be snipped off or carefully excised, and the pedicle or resulting wound ligated or stitched. Unfortunately, these growths tend to recur and multiply, so that their removal results in temporary relief only. They are not common. There is a rare form of papilloma of the rectum seen in adults; it resembles a mucous polyp, but may be mistaken for cancer. It has a broad base, but does not infiltrate the mucosa. Treatment is by excision and cautery. Cancer of the Rectum. — Many competent surgeons still feel that Fig. 41. — Benign tumors of the rectum (after von Berg- mann). TUMORS OF THE ANUS AND RECTUM 107 cancer of the rectum is always an incurable disease, and is susceptible of ])alliative treatment onl}-. This view is justified by the fact that a large majorit}^ of patients suffering from cancer of the rectum consult a physician only after the time during which radical measures are practicable. At the best, a radical operation is difficult and dangerous, and to insure success, should be undertaken early in the disease. A few recent statistics are slightly encouraging, if one may trust statistics. W. P. Petersen,^ of Heidelberg, reports operations upon 248 cases of rectal cancer, with a mortaHty of 13 per cent.; permanent cure, 18 to 20 per cent. — that means, patients living over ten years. John A. Hartwell - reports 46 cases with an operative mortalit}' of 26 per cent. Hupp ^ analyzes 881 cases with a mortality of 9.4 per cent. But re- ports vary in their estimates, some finding the mortality from operation to be as high as 70 per cent. Cancer of the rectum is composed of cj'lindric cells like the epithelium from which it grows. Adenoma develops from the lining of the crypts of Lieberkiihn. Early the ad- enomata may appear benign, but soon they take on malignant characteristics. AYe may divide true cancer of the rectum into three groups histologically: (1) Carcin- oma of the rectal wall in the ampulla, the commonest cancer of the rectum, making up about 65 per cent, of all the cases. This is adenocarcinoma, and is generally found on the anterior waU, just above the anus. (2) Fibrous tumors, high above the pouch of Douglas, from 2 to 3J inches above the anus. These tumors are hard, and vary in size from a walnut to an egg. These are the tumors which, encircle the bowel early and produce stenosis. This group comprises about 23 per cent, of the whole, and one remembers of them that these high-seated tumors form a ring of stenosis. (3) The third group is the most malignant, but the least common — from 12 to 15 per cent, of all. These growths are of a mucoid nature; they develop in and envelop the lower portion of the rectum ; they spread superficially and infiltrate the deeper tissues. Necrosis of these masses is seen commonh'; and on inspection there appears a blood}^ gangrenous tube, substituted for the normal rectum. The lymphatic connections of rectal cancer are of vital importance to the surgeon, because upon a knowledge of lymphatic extension depends the feasibility of successful excision. There are 4 lymphatic 1 Proceedings German Surgical Congress, 1903; Ann. Surg., December, 1903. 2 Ann. Surg., September, 1905. 3 Med. News, September 28, 1901. Fig. 42. — Scirrhus cancer of the rectum, i^von Berg- mann). 108 THE ABDOMEX connections: (1) Those draining the anal skin; (2) the intermediate zone of the anal portion; (3) the columnar zone of the anal portion; (4) the group draining the rectum proper. Evidence of involvement of group 1 may be found in the inguinal nodes. The other three groups drain upward into the nodes in the sacral hollow and along the superior hemorrhoidal arter}'. Remember this important fact, however, that all 4 of these groups have a liberal anastomosis, so that disease of any portion of the rectum may result in the involvement of other portions and in the enlargement of any one of these h^mphatic groups. Here are a few interesting statistics to be noted in passing: Cancer of the rectum causes about 0.3 per cent, of all deaths; it is twice as com- mon in men as in women. It is seen most frequently after forty, but cases as j'oung as twenty-three are reported. Indeed, it is a re- markable fact that rectal cancer has been known in children below ten years of age. Symptoms. — The early s^onptoms of cancer of the rectum are so indefinite that we cannot wonder at delay in establishing a diagnosis. The early S3'mptoms are slight pain and bleeding and are not character- istic; often they are so indefinite as to cause a patient no special in- convenience; often they simulate the symjDtoms of other lesions; most commonly they suggest hemorrhoids. Later, there may be a sense of fulness and increasing constipation. Later still, when the disease is well advanced, there are fairly constant pain, hemorrhage, a foul discharge with gangrenous odor, and the evidence of more or less com- plete intestinal obstruction. Constitutional disturbance is not a marked feature early; indeed, in the 46 cases reported by Hartwell cachexia w^as present in only one-third at the time of the operation. So it is evident that the diagnosis rarely can be made early — seldom in less than nine months from the onset of symptoms; often as late as two 5'ears. These cancer cases emphasize again the extreme impor- tance of making a careful examination of eveiy patient who complains of constant rectal disturbance. Age signifies little, as cancer of the rectum may occur in youth. Pain and occasional hemorrhage always should be investigated, and the diagnosis confirmed by digital explora- tion or by ini^pectiou with the proctoscope. Treatment of Rectal Cancer. — Ob^^ously, no mild measures will avail in cancer of the rectum unless, indeed, the patient and his friends prefer that he content himself with the euthanasia produced by opium — perhaps the preferable method in a majority of cases. The question of methods of operation is one which has occasioned wide and rather hot discussion, its answer depending probabty upon the notions and personal experiences of individual operators. The surgeon has to regard 3 factors in the problem : he must remove the cancer entire; he must combat sepsis; he must supply a satisfactoiy artificial anus. The first point rarely is met. Cancer usually returns. As for the second, sepsis is common after all operations upon the rectum, and as for the third, a satisfactory artificial anus rarely is secured. Let us consider briefly a few of the measures emploj'ed in attempting TUMORS OF THE ANUS AND RECTUM 109 to attain these desired results. It has come about that there are 3 main routes by which cancer of the rectum is approached : (1) Through the perineal or anal region; (2) through the sacral region; (3) by ab- dominal section. Approach to the cancer through the anal region gives no surety of complete and successful removal of the tumor, though in a certain number of cases success is attained. By this route the involved lym- phatics cannot readily be reached, and the employment of this method is no more rational than is resection of the cancerous breast, leaving the lymphatic connections undisturbed. Resection of the rectum through the sacrum, that is, by removing a portion of the sacrum, as recommended by Kraske and others, is a fairly satisfactory method. Low-lying cancer may thus be removed and involved lymphatics traced. But an incompetent anus, situated in an inaccessible region, nearly always results. The method to be preferred is extirpation through the combined abdominal and sacral or anal rovites. It is needless here to discuss at length the various arguments advanced by advocates of various methods. Suffice it to suggest that the abdominal route makes pos- sible a cleaner dissection, with less chance of sepsis, and establishes a fairly controllable artificial anus in an accessible region; but, most important of all, it provides an aseptic field, and renders possible a complete removal of the growth and a comparatively easy reaching of the h'mphatic channels. Bear in mind this important point also, that inasmuch as all the rectal lymphatics anastomose with more or less freedom, therefore cancer situated in any portion of the rec- tum, from anus to sigmoid, may give rise to cancerous lymph-nodes in any of the -i lymphatic drainage channels which I have described. Above aU things, the practitioner must remember that the presence of metastasis in other organs, notably, the liver, positively forbids ex- cision of the rectum. Through abdominal section only can such metas- tases be found. All operations for cancer of the rectum are difficult — not lightly to be undertaken. The surgeon must have an exact knowledge of the anatomy of the parts and an intelligent comprehension of his patient's general condition. At the best, both surgeon and patient are embark- ing upon a forlorn hope. The patient must be carefully prepared, whatever the operation employed, and a daily treatment of the bowels, for from one to two weeks, is in order, that the passage may be completely cleared. Everj^ morning before breakfast half an ounce of castor oil should be given, followed by an enema. The diet should consist of meat, eggs, and strong soups. For two days before operation the patient should be hniited to a liquid diet, and should be given opium. The last enema should be given not later than six hours before the operation. The Anal Resection. — With the patient on his back and his knees drawn up, the sphincter is dilated or divided posteriorly from anus to coccyx (Kocher removes the cocc3'x), and the new-growth is seized and 110 THE ABDOMEN excised with knife, scissors, or Paquclin cautery. Bleeding is controlled, the gap is sutui'ed, the posterior cut being drained with gauze, while a tube is left in the rectum. A more complete method is approach through the perineum. The in- cision is made from the middle of the perineum to or through the coccyx, encircling the anus. The anus and lower portion of the rectum are then carefully separated from surrounding tissues, when the bowel with the new-growth is drawn downward, bringing with it the branches of the middle hemorrhoidal artery, which must be tied. By proceeding care- fulh* in this manner, which usvially involves opening the peritoneal cavity, the rectum may be brought well down and cut off above the growth. The final step consists in suturing the stump of bowel, W'ith- out too much tension, into the wound, and packing around it with gauze to control hemorrhage. This method with various modifications is still frequently employed, but the danger from sepsis is great, and there is no possibility of removing thoroughly infected lymph-nodes. The Sacral or Dorsal Method.— Various operators, from Kocher, in 1874, have advised dorsal methods of approaching disease of the rectum; but to-day the most commonly accepted course is that advised by Kraske in 1885. The patient lies upon his right side, w^ith his thighs sharply flexed, and an incision is made in the middle line, from the anus to the sacrum, and from there along the left border of the saciTim to the posterior iliac spine. The gluteus maximus is divided, and hemor- rhage is checked. Then the sacrosciatic ligaments are divided close to the sacrum, nearly to the sacro-iliac synchondrosis. The lateral sacral arteries are secured, but the pubic nerve and vessels must not be injured. The cocc3^x is then cleared or removed, and the rectum exposed, ^"arious operators remove varying portions of the sacrum. The presacral tissues as high up as the second vertebra are pushed away from the bone, saving the sacral nerves only. In this way one includes all the lymphatic nodes and vessels which are a})t to be involved. Search must then be made for the superior hemorrhoidal arterj-, which lies in a fold of peritoneum behind the upper portion of the rectum. After ligating this artery the gut is freed posteriorly and laterally and the peritoneum is opened. Then, beginning well above the growth, the rectum, with its associated nodes, is removed from above downward, intestinal clamps having been placed upon it at the point of section. The whole of the rec- tum below the point of section, and including the anus, should be ex- cised; then the proximal portion of bowel is brought out and fastened in the sacral wound, provision being made at the same time for ample gauze drainage of the surrounding parts. So much for two of the methods commonh' employed. Combined Method of Resection. — A method of operating in two stages, and approaching the growth from above and from below, is growing in favor and promises to improve our statistics as regards both operative risk and permanent cure. The question of operation by the combined method involves also a discussion of palliative measures. Such measures are employed when TUMORS OF THE ANUS AND RECTUM 111 total resection of the tumor is impossible, when obstruction is nearly or entirely complete, and when pain is constant. Palliation consists in establishing an artificial anus by colostomy. It used to be known as Littre's operation, and has been in use for generations. The com- bined method of excision of the rectum is by two stages, and takes advantage of a prehminary colostomy. By this preliminary measure the bowel is efficiently drained, and the patient's general health is improved, because a sufficient nutritious diet may be administered up to the time of the final operation, while, owing to the previous colos- tomy, septic absorption is diminished or eliminated when the rectum is removed. In addition to Kocher's method of forming an artificial anus, already described, another satisfactory method is to bring out the sig- moid in the left groin, to cut it oft', leaving a voluminous pouch of bowel above, to draw the proximal end beneath the anterior sheath of the rectus muscle, and to estabhsh the new anal opening above the pubes in the median line. After this first operation the patient generally mends in surprising fashion, and he often declares himself to feel entirely relieved. If it is now determined to proceed to more radical measures, the second step is taken after an interval of from two to three weeks. This second step may be entered upon variously. The abdomen ma}* be opened from above at the same time that the sacral route is followed from below, and so a complete and thorough dissection of the pelvis may be accomplished. If the abdomen is opened, the superior hemor- rhoidal arteiy must be tied at once, and in all cases the ureters must be identified and isolated. Section of the ureters is a grave calamity, which has happened in many cases. The best position for the patient, for approach by the sacral route, is in the exaggerated knee-chest posture, which controls remarkably the venous oozing. Many operators prefer to work entirely along the sacral route, and not to open the abdomen from above at the time of this second operation. Probably this method involves less risk of sepsis. The method then is quite similar in technic to that of Kraske. The rectum may be drawn down after the superior hemorrhoidal artery is Hgated, until the blind end, which was tied off at the preliminary opera- tion, has been delivered. This elimination of the whole lower bowel, lea\Tiig no blind pouch behind, is probably the best method of opera- tion. Thus the entire mass is completely excised, and the entire rectum is removed, with its attached glands and lymphatics, down to and in- cluding the anus. The peritoneum is then closed, and the superficial wound sutured about a small drain, which must be left. There is always considerable shock following these operations, so that the patient must be carefully watched afterward and symptoms must be met as they arise. Feeding may be done through the artificial anus until the stomach is ready to take care of nourishment. Numerous modifications of the combined method of excision have been devised. Powers ^ recommended operating on women by working ^ C. A. PoTv-ers (Denver), Boston Med. and Surg. Jour., January- 21, 1904. 112 THE ABDOMEN from above and through the vagina, instead of through the sacrum; the entire rectum is thus readily removed. This method is essentially that which has been pojuilarizcnl by J. B. Murphy. The student of the literature should also familiarize himself with W. J. Mayo's modifica- tion of Maunsell's method, as well as with the operation of Weir.^ All these operations are difficult and dangerous at the best. The immediate mortality is high, and recurrence is conunon; but accumu- lating statistics seem to show that in the hands of competent surgeons, and of competent surgeons only, excision of the rectum, especially by the combined method, holds out promise of a radical cure, or at least of relief from pain, and a prolonged remission of symptoms. 1 Med. News, July 27, 1901. CHAPTER IV THE ESOPHAGUS, STOMACH, AND DUODENUM We have made some study of the intestines and rectum, and have been able to arrive at a general understanding of such of their diseases as concern the surgeon ; and we have observed this supremely important fact, that the digestive tract is continually subjected to the presence of foreign substances — food and the products of digestion. These substances are there, indeed, to meet physiologic demands, but their Fig. 43. — a, Bougies or sounds; h, bulbous sounds; c, English rubber sound with funnel and openings at the tip; d, Trousseau's olive-tipped bougie (Keen's Sur- gery). mere presence is at times an irritation to the organs, and always they carry with them malign organisms. The non-functionating gut of a fetus is practically sterile; the active gut of an infant or of an adult is loaded with bacteria, capable of setting up the most severe infections. Let us turn now to the upper portions of the alimentary tube, — the esophagus, stomach, and duodenum, — and note the diseases which 8 113 114 THE ABDOMEN occur in them, observing that in spite of minor differences in function all parts from pharynx to anus are of a generally similar structure, are subject to much the same influences, and develop similar disease processes. As we have seen that inflammations, obstructions, and new- growths are the important lesions of the intestines, and as we shall see later that ulcer and new-growths are the important lesions of the stomach, so we must now observe that obstructions, new-growths, and malformations are the imjjortant lesions of the gullet; but we observe at the same time that all such lesions are common to all portions of the alimentary tract. The Esophagus When you pass a tube or bougie into the stomach of an adult, re- member that the average distance from incisor teeth to cardia is 16 inches. Moreover, as the trend of the esophagus is gradually from median line to the left of the spinal column, the operator must observe ■ I Fig. 44. — Starck's diverticulum sound (Keen's Surgery). that right to left direction in passing an instrument or the esophago- scope, and he must cut upon the left side of the neck in the operation of esophagotomy. The commonly employed instruments for examin- ing the esophagus are bougies and olive-tipped probangs of graduated sizes. By their use strictures, pockets, and diverticula may be dis- Fig. 45. — Esophageal stricture. Shows Schreiber's dilating sound in position (Keen's Surgery). covered, and foreign bodies may be detected. Various forms of endo- scopes are used for the inspection of the gullet, but the most satis- factory is some form of straight instrument, as recommended by von Mikulicz. By any of these instruments it is possible to make out also the rare malformations, congenital occlusions, and fistulas. STRICTURE OF ESOPHAGUS 115 Fig. 46. — Von Mikulicz set of instruments for esophagoscopy. STRICTURE OF ESOPHAGUS Stricture is far the most common lesion of the esophagus with which the surgeon has to deal, and in exploring for stricture the beginner must remember that there are 4 normal narro wings in every esophagus — at its beginning, behind the cricoid cartilage, opposite the tracheal Fig. 47. — Permanent cannula (after von Leyden-Ren vers). bifurcation, and at the cardia. Moreover, there are two important varieties of stricture — mahgnant and cicatricial — the latter usually caused by some corrosive poison. In more general terms these stric- tures are due to the healing of an ulcer — from any traumatism, chronic inflammation, tjTDhoid ulceration, syphiHs, tuberculosis, prolonged vomiting, small-pox, or gout. A common seat of stricture is at one of the normal esophageal narrowings. The stricture may be single 116 THK ABDOMEN or multiple, clci)eiKliiig on the cause. Pressure from without, as by a tumor, may cause constriction, but this is not properly stricture; nor must the surgeon forget that form of dysphagia, or difficulty in swallowing, known as spasmodic stricture, commonl}- of a hysteric nature, and freiiuently relieved by the passage of a bougie. Fig. 48.^Symond's esophageal tube (Keen's Surgery). We need not consider in detail the pathology of the cicatricial stric- tures. Suffice it to remind the student that the initial injury is fol- low^ed by an inflammatory reaction which gradually subsides, with healing by granulation and the production of a firm fibrous cicatrix, whose breadth and depth depend on the extent of the original injury. ^^ Fig. 49. — The window-plug for the esophagoscope. Upper figure, the esophago- soope, made air-tight by tlie window-plug. Lower figure, the winilow-plug, e.xact size, and a cross-section of the esophagoscope, actual size. The plug is taken out and inserted at will.i The symptoms will vary with the progress of the disease. Early there are pain, distress, and a sense of burning, which pass in a few days. Then, as the gullet lumen contracts, there comes difficulty in swallowing, 1 " This is the tube which I prefer. It should be called the Einhorn-Jackson- Mosher tube. The window-plug is mine. This tube for adults should be of tivo lengths— 10 inches and 18 inches."— Statement by H. P. Mosher. STRICTURE OF ESOPHAGUS 117 which may increase until Hqiiids even fail to pass; but the tube dis- tends above the stricture, as occurs in the case of strictures elsewhere. Fig. 50. — Method of introducing esophageal bougie. Tlie bougie is bent before it is introduced (Keen's Surgery). Fig. 51. — Method of introducing esophageal bougie. Position I: The head in ex- tension until the bougie reaches the esophageal entrance (Keen's Surgery). Thus the esophagus becomes sacculated and the sacculation gradually attains a considerable caliber, so that quantities of food lodge there. From time to time the patient vomits this accumulated material. 118 THE ABDOMEN Sometimes the vomitus is bloody; sometimes it is composed of saliva and mucus. The patient becomes feeble and emaciated. He suffers from hung(>r and thirst. There may be pain or a sense of discomfort in the region of the stricture, or over the epigastrium and in the back. Fig. 52. — Method of introducing esophageal bougie. Position II: The chin brought down almost to the chest; the bougie glides into the esophagus (Keen's SurgerjO- Such a history points to the diagnosis of esophageal stricture, of which the presence is confirmed by exploring the gullet with bougies. The first step in treating these strictures is to ascertain their size. We use for this purpose olive-tipped bone probangs, taking care not to damage the wall of the gullet, for one hears dreary tales of incautious GUIDE BOUGIE StHOLLOW DILATING BOUGIE S String Tunnel Oesophagotome. Oesophagotome MoDiriED. Fig. 53. operators who have passed instruments through the wall of the esophagus into the trachea, the mediastinum, and even into the aorta. If the stricture will admit a probang, one may proceed to dilate the narrow opening with flexible bougies in the manner illustrated by the figures. In this way most strictures may be dilated readily, and when STRICTURE OF ESOPHAGUS 119 stretched to a comfortable size, may be kept open by the occasional passage of an instrument. You must warn the patient that the stric- ture is liable to recur unless it be watched and treated occasionally. Then there is that class of tight strictures on which Abbe and Mixter have experimented, and for which Dunham and Plummer have devised their ingenious instruments.^ The appended cuts (Figs. 53, 54, 55) show graphically the technic of Dunham's method, which, in common with man}' other surgeons, I have used with satisfaction. There are two distinct sets of apparatus, but the principle of both is the same: the stricture is saAved through with a thread. The first apparatus is used for strictures through which a guide may be passed. An olive tip fol- lows and engages in the stricture. Over the olive there plays a stout thread, which is pulled back and forth against the stricture until it cuts a way for the instrument, which is then pushed on into the stom- ach. Anesthesia is not needed. K. THREAD-WASHING THROUGH MOUTH AND THROUGH NOSTRIL. Fig. 54. Dunham's second apparatus is for tight strictures which will not take a guide. For such, a preliminary gastrostomy is necessary, and this artificial opening must be kept open until after the secondary operation, A thread is then washed down from mouth to stomach, one end being retained above. The thread end in the stomach is then hooked out, and a stout double linen thread is dra"^Ti through the gullet. There are now two threads in the esophagus. By one a 'Svire-and- spindle bougie" is drawn up against the stricture from below. The other thread plays over and alongside of this bougie, and so cuts out a path for the larger instrument. Dunham's method of passing the first thread dovm into the stomach is curiously mgenious: The thread of silk, several feet long, is fed through a funnel and drinking tube into the mouth of the patient, who 1 Theodore Dunham, New Instruments for the Treatment of Esophageal Stric- ture, Ann. Surg., 1903, vol. xxxvii, p. 350. 120 THE AHDOMKN swallows wiiter slowly poured into the fuiin(>l. The descending stream quickly carries the thread tlu()Ui;h the closest and most tortuous stric- tures into the stomach. When a stricture has been sufficiently dilated by this method, the gastrostomy opening is closed, and a patent esophagus is maintained by passing a bougie occasionally — perhaps two or three times a year. Dunham's method is applical)le to all strictures through which a stream of water can pass. In the case of impermeable stric- tures, a permanent gastrostomy is required to avert starvation. Mixter, at the Massa- chusetts General Hospital, had a remark- able case in which the destructive agent had obliterated not only the lumen of the esophagus, but that of the stomach also. The patient is now comfortably nourished through jejunostomy, and he thrives after six years, his only complaint being that he can swallow no better than before the opera- tion! Artificial. Oesophagus. CARDIOSPASM TO ILLUSTRATE THREAD-WASHING. Fig. 55. The term cardiospasm has been applied in recent years to a stricture of the cardiac end of the esophagus, associated with dilata- tion of that tube. It is probable that the term ■ is still used to embrace a greater variety of esophageal changes than should be indicated by a single word. We know, for example, that a sudden acute spasmodic closure of the cardia may take place, ex- actly resembling a spasmodic closure of the P3'lorus. This sudden closure of the cardia is called acute cardiospasm. Furthermore, there is chronic cardiospasm, for which various causes are assigned — kinking of the esophagus, esophagitis, atony, degeneration of the fibers of the pneumogastric, and primary long-continued spasm. The last two causes, assigned by von jMikulicz and Kraus, may very well co- exist, and are probably the most common. In other words, we see that cardiospasm, so called, may be acute or chronic, may be j^rimary or secondary. These cases usually go unrecognized for a long time. At first the patients are thought to have a disease of the stomach. Again, the diagnosis of cancer of the esophagus freciuenth' is made. The symptoms are those of pressure in the epigastrium, and fulness, which is relieved by vomiting, while the vomitus is always undigested food containing no hydrochloric acid, pepsin, or rennet. There may be dyspnea and hoarseness. We ascertain the exact condition by CARDIOSPASM 121 passing- bougies or stomach-tubes, which may or may not engage in the stricture and pass it with chfficulty. The Ilocntgen-ray picture is characteristic if the suspected pouch be filled first with a mixture of potato and bismuth porridge. Best of all, the esophagoscope gives an excellent picture of the condition. That form of the dis- ease with which surgeons are most specially con- cerned is the chronic foi'm. Chronic cardiospasm lasts many years. The con- striction becomes gradu- all}' tighter and tighter; the dilatation of the esophagus greater and greater, the patient's nu- trition more and more dis- turbed, until, finally, death from starvation results. Von Mikulicz believed also that cardiospasm predis- poses to cancer. The treatment is symp- tomatic and is direct. The symptomatic treatment means a careful dieting, abstinence from all stimu- lants, and daily lavage with astringents. The local application of cocain has been found useful. In the case of acute attacks with complete obstruction, rectal feeding may be necessary, or gastrostomy even. Various ingenious devices for dilating the stricture have been em- ployed, and are undoubt- edly serviceable, but at the best they seem to be palliative merely. Assum- ing the disease to be primary, von Mikulicz cured a few chronic cases by opening the stomach and forcibly stretching the stricture. The disease is coming to be regarded as more common than was thought a few years ago. Certainly the complex of conditions is extremely in- teresting, and is still in process of elucidation. Fig. 56. — Anatomic preparation from a case of cardiospasm with saccular dilatation of the esoph- agus. A drainage-tube is seen in the cardiac seg- ment (Keen's Surgery). 122 THE ABDOMEN DIVERTICULUM OF THE ESOPHAGUS Diverticulum of the esophagus is a condition cHnically aUied to stricture at times. That is to say, its sj-mj^toms may simuhitc those of stricture. Moreover, we are coming to beheve that it is a rather com- mon condition. M. H. Richardson, writing eight years ago, stated that a search through the literature disclosed but 56 cases of esophageal diverticulum; on the other hand, Riebold ^ says that such diverticula have been found in 3.5 per cent, of all autopsies in adults, but that they have never been seen in children under fifteen years. Be all that as it may, no one surgeon can point to a great list of these cases. Fig. 57. — Diverticulum of esophagus (after Ricliardson). Diverticula are pouches, varying in size, springing from some portion of the esophagus, and somewhat resembling a gall-bladder in shape. A true diverticulum is lined with mucous membrane. There are three varieties — traction diverticula, due to the adhesions and pulling of scars external to the esophagus; pressure diverticula (sometimes called pulsion diverticula), due to pressure from within; and traction- pressure diverticula. These diverticula are variously placed, but most commonly are found at the junction of the pharynx and esophagus. Rarely they are as low as the mediastinum. Generally, they lie behind the esophagus, between it and the spinal column. Diverticula may or may not give rise to s5anptoms, which will 1 Virchow's Arch., vol. clxxiii, No. 3. FOREIGN BODIES IN THE ESOPHAGUS 123 depend on the site of the opening, the size of the diverticulum, and its capacity for incommoding by pressure. Symptoms may vary all the way from a sense of thickness in the throat and a tendency to clear away nnicus, to dysphagia, nausea, vomiting, and sundry pains due to pressure by the distended pouch. Sometimes a tumor is seen in the side of the neck, and the swelling may be obliterated by pressure; sometimes there is no tumor apparent. Sometimes the diverticulum fills with food before food will pass to the stomach. Frequently a bougie will not pass into the stomach unless the pouch is full of food. Erroneously, this has been asserte^cl to be an invariable sign. The stethoscope may detect fluids passing into the pouch. Mix food with bismuth subnitrate and allow the patient to swallow it into the divertic- ulum, when a satisfactory skiagraph of the pouch may be taken. Fig. 58. — Diverticulum of esophagus (after Richardson). Treatment. — The only radically satisfactory treatment of divertic- ulum is by excision, when the sac is within surgical reach. Cut down on the left side of the neck, directly over the sac; cut off the sac, cau- terize the stump, turn it in, and complete the operation with a row of Lembert stitches in the esophageal wall. A small diverticulum, without being opened, may be inverted into the esophagus. Avoid always the recurrent laryngeal nerve. Sew up the wound with drain- age. Dress the wound with an extra large absorbent dressing, and fix the head for five days in a Thomas collar. For the first three days after operation give no food by mouth. FOREIGN BODIES IN THE ESOPHAGUS Regarding foreign bodies in the esophagus, an abundance has been written. Yet the subject is simple. It has attracted a multitude 124 THE ABDOMEN of writers, because foroif2;n bodies in the esophagus are a commonplace of practice. All sorts of objects, from coins and fish-bones to open safety-pins and plates of false teeth, have lodged in the esophagus. When they lodge and stick, they make trouble. D. \\'. Cheever, one of the first of American surg(>ons to perform esoijhagotomy, delivered a famous lecture on thit^ tojjic. Foreign bodies make trouble because they obstruct the passage of food, primarily, and because they damage seriously the esophagus, secondaril3^ They damage the esophagus either by wounding it sharply, rarely by passing through it, or by setting up an ulcerative process, leading, if unrelieved, to extensive and alarm- ing inflammation. The student must remember that most foreign bodies lodge commonly at one of the points of physiologic constriction, Fig. .59. — Esophageal instniments: a, h, Forceps; c, horsehair probang; (/, coin- catcher; e, esophageal bougie. but small sharp articles, like fish-bones, catch in the tonsils usually. In any case foreign bodies should be removed as soon as possible. As to treatment, there are obviously three methods of extracting foreign bodies; through the mouth, through the stomach, and through the neck by esophagotomy. A great many substances may be pulled up or pushed down by proper instruments introduced through the mouth — bougies, coin-catchers, the umbrella probang; though one must remember that these measures are not altogether devoid of danger, as coin-catchers have been known to stick or break off in the gullet. For this reason it is well, if possible, to obtain a sight of the foreign body with the esophagoscope or the .r-ray. M. H. Richardson, in 1886, was the first to demonstrate the feasibility of remo^•ing foreign TUMORS OF THE ESOPHAGUS 125 bodies through the stomach. He ch-ew out and opened the stomach, passed in a forceps, and removed a phitu of false teeth lodged just above the cardia. Bodies may also be removed from the eso]jhagus by passing down a large-sized endoscope, such as is used in the urethra, and grasp- ing the offending object with pliers introduced through the endoscope. Failing other means, one may employ esophagotomy, which consists in opening the esophagus on the left side of the neck in the region of the anterior belly of the omohyoid muscle. Through such an opening the esophagus may be explored with the finger or with instruments, and any foreign body, except the most low lying and firmly impacted, may thus be removed. Esophagotomy is followed commonly by slow healing and an infected w^ound. The esophagus may be stitched up with catgut, and the external wound drained. Various other ingenious devices have been employed in special cases, but the main principles are those already laid down. TUMORS OF THE ESOPHAGUS Tumors of the esophagus are common ; next to benign stricture and foreign bodies, they constitute the most important and interesting group of lesions of the esophagus with which the surgeon has to deal. Benign tumors are not common, but cancer is a frequent affection, as one would expect w^hen dealing with an organ so subject to traumatism as is the esophagus. Of the benign tumors, one should remember that cysts, 'papillomata, myomata, and polypi are occasionally found, and may prove trouble- some. Ivlebs points out the interesting analogy between diseases of the esophagus and those of the external skin. These various benign tumors may cause slight or marked symptoms. The important evi- dence of their presence is difficulty in swallowing; but one can estabHsh a positive diagnosis by the esophagoscope only. Obviously, these tumors can be removed by surgical measures alone — by snaring, by excision, or by the cautery, when they are within reach; or they may be approached through esophagotom3^ Sarcoma of the esophagus rarely occurs. It runs a rather rapid course and is uniformly fatal. Any attempt at treatment must be along the lines to be suggested for cancer of the esophagus. Cancer of the esophagus ^ is one of the most grievous and fatal diseases known. We see it in daily practice and in every surgical ward. Its site is generally at one of the normal esophageal narro wings, especi- ally behind the cricoid and just above the cardia. It, too,^ causes dysphagia as a first symptom — dysphagia which may steadily increase from the beginning until there is complete occlusion, or rarely may appear late in the disease only. That depends on the anatomic arrange- ment of the cancer, whether it encircle the gullet or grow to a considera- ble size without encroaching specially upon the lumen. Gnawing, 1 For an admirable recent bibliography on cancer of the esophagus see the article by M. G. Seelig, Ann. Surg., December, 1907, p. 809. 126 THE ABDOMEN continuous pain often is present — sometimes over the seat of the disease, sometimes in the epigastrium or between the shouklcr-V^lades. Of course, one observes also the rapid cachexia, more pronounced than cachexia of cancer elsewhere, because starvation is added to the toxic process. In other respects encircling or occluding cancer causes symp- toms similar to those of benign stricture — the spitting up of undigested food and occasionally bloody or foul expectoration. The patient's breath is noticeably offensive. Moreover, when cancer of the esophagus is low lying, it may involve the fundus of the stomach and give rise to a train of symptoms resembling those of gastric cancer. From the history of cachexia, emaciation, pain, and obstruction a diagnosis of cancer can be made almost with certainty. Of course, a positive diagnosis is of great importance, and to establish this, the esophagoscope is useful sometimes; or bits of tissue may be removed with the sharp spoon or the tip of an esophageal instrument. Treatment is by palliation. I have rarely seen a cancer of the esophagus which lent itself to an attempt at radical removal. Pallia- tive measures include morphin, the passage of bougies, and in a few cases the insertion of a hollow tube to be worn permanently. If there be complete obstruction and if the patient's strength permit, one may stave off starvation by establishing a peraianent feeding-opening in the stomach — gastrostomy. The old routine in all cases of esophageal stricture of doubtful origin is to give a course of potassium iodid, with syphilis in mind. Sometimes this does no harm, but the treatment should not be continued longer than two weeks if no benefit results. Several operators have performed radical removal of the growth, but no case of permanent cure is recorded. Recent experiments have shown that it is feasible to enter the mediastinum from behind and to resect the esophagus in its lower portion, the Sauerbruch cabinet or some similar device being employed at the same time to favor expan- sion of the lung. At the present writing there is no satisfactory evi- dence that such procedures promise benefit to these unfortunate patients. INJURIES OF THE ESOPHAGUS In addition to the diseases of the esophagus already discussed, there are certain other conditions with which the surgeon occasionally may concern himself. There are injuries, which the writers are wont to treat under various headings, though, in fact, I have already referred to this subject in dealing with foreign bodies and with stricture. In- juries due to foreign bodies explain themselves. I have seen the esophagus ruptured by a fall upon the head, and writers report cases of rupture of the esophagus due to vomiting. These patients almost always die from sepsis, but the effort of the surgeon must be to provide proper drainage and to nourish the patient without irritating the wounded tissues. THE STOMACH 127 INFLAMMATIONS OF THE ESOPHAGUS Inflammations of the esophagus occur at times and may interest the surgeon. They may assume various forms, such as acute or chronic catarrhs, and necrotic or diphtheric inflammations. These inflamma- tions may be ascertained by the use of the esophagoscope. Treat- ment is rather uncertain. If the disease is mild, relief and cure follow the administration of a cool liquid diet and the use of general tonics. If the disease is more severe, it may be necessary to make local applica- tions with such solutions as silver nitrate (1:4000) or a 5 or 10 per cent, solution of argyrol. Ulcers of the esophagus occur also — gangrenous ulcers caused by pressure from within or from without; syphilitic ulcers in the upper portion; rarely tuberculous ulcers; and actinomycosis of the esophagus has been described. It appears also that peptic ulcer of the esophagus^ may be found as well as the curiously uncommon typhoid ulcer. All these latter lesions are curiosities of surgery. They can be ascertained by the use of the esophagoscope, and by the recognition of associated general disease, while their treatment, with the exception of that for actinomycosis, must be along general systemic lines. The Stomach The stomach has become an organ of supreme interest to surgeons in these days. Within the past ten years the literature of gastric surgery has grown to enormous dimensions; and advances in accuracy of diagnosis, in confidence of treatment, and in operative technic have been in proportion. We have seen how the appendix with its various manifestations of disease dwarfs the importance of most other ab- dominal organs, and how its disturbances have a special bearing on digestive disorders. In like manner the stomach, ulcerated, catarrhal, or the seat of malignant disease, looms up as an organ continually sub- ject to surgical observation and treatment. Gastric surgery is more than thirty years old, but for the first fif- teen years its progress was halting and unsatisfactory. So long ago as 1880 von Mikulicz sutured a perforation on the lesser curvature of the stomach, but the patient died, and in the year previous Pean at- tempted a pylorectomy, — unsuccessfully, — to be followed by Rydygier in 1880. Billroth improved the operation and saved his first patient in 1881, while Rydygier excised successfully an ulcer in 1881, and in the same year Wolfler performed the first gastro-enterostomy. Up to that time, and until much later, indeed, lesions of the stomach were regarded as belonging to the domain of the internist acting alone, but of recent years we have come to see that many disorders of diges- tion are due to anatomic changes which disturb the stomach's mechan- ism and demand mechanical interference for their relief. For instance, ^ Peptic Tilcer of the esophagus is well recognized and may lead to stricture. Considerable literature on this subject is summed up by Wilder Tileston, Peptic Ulcer of the Esophagus, Amer. Jour. Med. Sci., August, 1906. ]28 THK ABDOMKX a narrowed ])yl()rus will ahva}'s ol^slnict tlu; onward ])assa,i;o of food until the opening has been enlarged by the surgeon. Observe, too, the vital importance of associated diseases of sundry abdominal organs. Such association, accompanied with misleading s^'uiptoms, renders extremely difficult the physician's task, if, on the evidence of symptoms alone, he attempt to name a particular oi'gan as the one at fault. Gastric ulcer, cholangitis, pancreatitis, and peri- gastritis may give rise to identical trains of symptoms. The recognition of such facts has led to the conviction that diseases of these various abdominal organs must be studied together, for these diseases form a complex 1)ut interdependent group. Another important point in considering diseases of these organs, which we group under the name digestive organs, is that they all bear a definite relation to the duodenum. The duodenum is their central KiDNay \app Fig. 60. — Diagrammatic representation of the organs whicli lie near or are drained through tlie duodenum. chamber or clearing-house. The stomach, the common bile-duct, and the pancreatic ducts empty into it, and in it there take place the most important digestive changes. Moreover, through an interesting ar- rangement of the intestinal innervation, disease ofthe vermiform appen- dix causes reflex irritation of the stomach; while ptosis of any of the abdominal organs may set up a great variety of distressing " dyspeptic " symptoms. Bearing in mind then the close anatomic, physiologic, and patho- logic relations of the abdominal digestive organs, let us take up in detail a brief consideration of stomach and duodenal diseases, so far as they concern surgeons. Ulcer and cancer are at the bottom of most operable gastric dis- orders, but we must name also the complications of ulcer — pyloric obstruction; gastrectasia, or dilatation of the stomach; hemorrhage; PEPTIC ULCER 129 distortion of the stomach (hour-glass stomach); adhesions; tetany. Then there is that curious condition, spasm of the pylorus; stenosis of the pylorus in infants; cirrhosis and gastroptosis. PEPTIC ULCER It is probable that 5 per cent, or more of all mankind suffer from gastric or duodenal ulcer, first and last. The precise frequency of such ulcers seems impossible to determine, however, and the fact that scars of old ulcers are often found at operations and postmortem, when the patient gave no history of symptoms pointing to ulcer, suggests that peptic ulcer is more common than has been supposed. The cause of peptic ulcer is still a matter of dispute, though the actual condition present seems to be a_localized necrosis acted upon persistently by the digestive fluids. Women are afflicted, compared Fig. 61. — Acute round ulcer with perforation (Warren Museum, Harvard, 8476). with men, in the proportion of six to four. Age has an extremely important bearing on the subject, for peptic ulcer in the young is a more acute and remediable disease than is^peptic ulcer in the middle- aged. Bear in mind always this interesting fact that in 3'oung women of the chlorotic type (more rarely men) one expects acute ulcer. In men (more rarely women) between thirty and fifty one expects cnronic ulcer. The acute ulcers are curable b}" simple measures, as a rule. The chronic ulcers call often for surgical intervention, though both of these statements are subject to exceptions. A majority of peptic ulcers are found in the pj^loric portion of the st_omach and the first three inches of the duodenum; and such loca- tions have an important bearing upon the complications which may ensue, as well as upon the nature of surgical treatment. Three varieties of peptic ulcer are described: (1) The acute round ulcer, punched out, as it were; (2) the irregular burrowing, chronic 9 130 THE ABDOMEN ulcer, which may involve large areas of the stomach; (3) erosions of the mucosa. The acute round ulcer may run into the chronic form, or it may progress rapidly to perforation. Most commonly it heals spontane- ously. It may gi\e rise to hcmorrluujc or it may V)e associated with little or no hemorrhage. Often it causes boring, loj-alized ^viin and tenderness; occasionally there is no pain. In more than 90 per cent, of the cases it clauses 'Vomiting; In nearly 80 per cent, of the cases the vomitus is bloody. Chronic ulcer ma}' be developed out of acute idcer, and its course may run over years. If it has attacked the nuiscularis, it may never heal. It causes pain in nearly Un per cent, of cases, audit cauacs vomiting more often even. The bloody vomit- ing of chronic ulcer is as com- mon as that from acute ulcer, and tenderness in the ejjigas- trium beneath the left shoulder- blade, or about the tenth left rib, is a frequent s3-mptom. Erosions are often impossible to distinguish postmortem. They are slight abrasions of the mu- cosa, and ma}'' be single or numerous. Such is the condi- tion described as "simple ero- sions" by Dieulafoy. He also described a form to which he applied the term "ex ulceratio simplex," which is more exten- sive than the simple erosion, and may expose .small arterioles, giving rise to excessive — even to fatal — hemorrhages. Erosions are found in all parts of the stomach. Peptic ulcers may be single or multiple, and it is likely that they are multiple more often than generally is supposed. A common estimate is that 19 per cent, of all cases show multiple ulcers. Ulcer of the duodenum may be associated with gastric ulcer — the pres- ence of the one does not rule out the other. The course of peptic ulcer is as various as its form. Both the acute and chronic varieties may perforate; both may set up extensive perigas- tric inflammation ; both may cause adhesions to neighboring organs. The chronic ulcer leads to far more extensive and crippling inflammation, perforation, adhesions, and malformation than does the acute. Ulcer on the posterior surface of the stomach is not likely to cause so alarm- Fig. 62. — Chronic gastric ulcer ("Warren Museum, Harvard, 2199). PEPTIC ULCER 131 ing a form of perforation as is anterior ulcer, for adhesions do not form so readily on the anterior surface. Perforation may give rise to im- mecHate outi^ouring of gastric contents and to a general peritonitis; or through adhesions and locaHzetl abscess a more chronic form of disease may be established, with pockets of pus, forming most commonly behind the stomach in the lesser cavity of the peritoneum, causing sub- diaphragmatic abscess, or, in rare cases, subphrenic pyopneumothorax. Karcly fistulie form, Avhich may connect the stomach with the gall- bladder or the intestines, or may penetrate through the skin. Hemorrhage from peptic ulcer is extremely variable. Four varie- ties of hemorrhage are described : (1) Frecpent slight hemorrhage, — venous or cajDillary oozing, — sapping vitality, leading to profound anemia, often long undetected — a serious matter. (2) Intermittent hemorrhage of considerable quantity, probably from a small eroded artery. This rarely ends with fatal bleeding, but the patient becomes profoundly depressed. (3) Acute and profuse hemorrhage, frequently repeated. It may kiU the patient. (4) An overwhelming, quickh' fatal hemorrhage, due to the erosion of a large artery. The reader wiU see then that the progress of peptic ulcer may lead to two alarming conditions, — perforation and hemorrhage, — while the healing, or attempted healing, of an ulcer may lead to serious rnechan- ical distortion or crippling, through cicatrization. The important varieties of mechanical crippling are pyloric stenosis and hour-glass stomach. Pyloric stenosis is an affair of gradual onset. Generally, it does not at once interfere with gastric function and plug back or delay the chyme, because the gastric muscularis undergoes compensatory hypertrophy arid succeeds for a time in overcoming the pyloric obstruction. In the course of time, however, the muscular activity of the stomach fails to respond satisfactorih^, so that the gastric tonus is lost, when a thin- ning and dilatation of the stomach-wall ensue. These pyloric cica- trices ma}' form bunches of considerable size. They may appear as mere slight encircling bands, or as indurated masses as large as a hen's egg, and palpable through the abdominal wall. Distoiiion of the stomach, or hour-glass stomach, as it is commonly called, is due to contracting cicatrices, furrowing the wall of the stomach, and throwing that organ into a series of two or more pouches. Ulcer of the duodenum, bears a close resemblance to ulcer of the stomach; but being situated in a thin-w^alled organ, as contrasted with the stomach, it is more serious in its consequences, though its progress is not always obvious to the patient. In proportion to its frequency, duodenal ulcer perforates more often than does gastric ulcer. HemorrhageTFom duodenal ulcer occurs in the same fashion as hemorrhage from gastric ulcer, but the bleeding is somewhat more wont to be abundant and lona; continued. Duodenal blood generally is 132 THE AHDOMKN' passed off through tho bowel; rarely it enters the stomach. Gastric blood is usualh' vomited; sometimes it is passed off by the bowel. Symptoms. — The symptoms of peptic ulcer will suggest themselves to the student who is familiar with the morbid anatomy, and the symptoms will be found to \'ary with every case stuilied. A few years ago students were taught that a definite train of symptoms was necessary for the diagnosis, or for the consideration even, of peptic ulcer — pain, tenderness, "dyspepsia," and coffee-ground vomitus, or melena. Recent experiences of surgeons convince us that ulcer may exist for years without causing such classic symptoms. For example: I was recently consulted by a physician who told of persistent anorexia, with occasional voimiting, for ten years. There was no pain; there was no hemorrhage; he was not prostrated. Occasionalh' he was troubled by a sense of soreness and tenderness on pressure below the tip of the xiphoid. Convinced that he was the victim of a chronic inflammatory process which might lead to malignant disease in later life, he asked me to do an exploratory operation. I found an hour- glass stomach, surrounded by numerous and dense adhesions. No active ulcer was present. Gastroplasty after Finney's method com- pletely relieved his symptoms. What, then, are the symptoms of peptic ulcer with its sequela^, or how shall we make a diagnosis? That is one of the most difficult problems of abdominal surgery. If the clas.sic symptoms— pain, vomit- ing, and hemorrhage — be present, the problem is easy; but I believe that in many cases of ''dyspepsia" gastric ulcer or its complications is present without many or all the classic sjinptoms. Carefully con- ducted laboratory tests help us to a diagnosis. In the presence of peptic ulcer hydrochloric acid is increased generally. Slight traces of blood in the stomach may be detected b}- the guaiac test.^ These investigations may be made by the use of the stomach-tube, and the gastric contents must be expressed. Vomited gastric contents give a much less satisfactory test. We have to deal with a s}Tnptom- complex. Pain, preceding and relieved by vomiting, at a varying period after meals, — one to three hours, — associated with excess of free hydrochloric acid and blood in the stomach, makes the diagnosis of ulcer reasonably sure. Tenderness on j:)ressure in the epigastrium is a frequent symptom. In the case of an old ulcer with a thickened base the mass may some- times be felt in the pyloric region. 1 Guaiac test: Fresli alcoholic solution of guaiac should be made by scraping with a knife a few grains of gum guaiac into a test-tube containing aljout 5 cc. of alcohol, in which the guaiac (juickly dissolves. It is better to select that portion of the gum guaiac api)earing as yellow nuggets on the surface. A few drojjs of hydrogen dioxid are added. The stomach-contents or the waterj- mixture of feces to be examined are mixed in a test-tube with one-third their volume of glacial acetic acid, and the wiiole shaken with an equal volume of ether. On standing, the ethereal extract containing the hemoglobin, if present, will .sej)arate and occupy the upper portion of the mixture in the tube. A few drops of this ethereal extract are next added to the alcoholic guaiac solution, and if blood was i)resent in the original material, a blue-violet color sliould appear in the mixture. So delicate is tills test that meat in the s-tomach-contents will give the blue color. PEPTIC ULCER 133 The general s}-mptoms — loss of weight and anemia, with diminished total amount of urine excreted, and chronic constipation — are also suggestive. The symptomatology of duodenal ulcer is more obscure than that of gastric ulcer, and the two are often indistinguishable. In duodenal ulcer, however, the pain may be more to the right of the middle line, and blood must be looked for carefully in the stools, rather than in the vomit us. There may be no vomiting. The blood passed by the stools may be in minute traces only, or it may appear in large, tarry masses. Perforation occurs in about 6.5 per cent, of all cases of peptic ulcer. The symptoms of acute perforation are overwhelming pain in the epi- gastrium, followed by a general or localized peritonitis. The acute pain signifies acute perforation, and is far more serious than the chronic, slowly progressing perforations, which become limited by adhesions to surrounding organs. Diagnosis. — The diagnosis of peptic ulcer has been indicated in the foregoing paragraphs. One looks for a long train of dyspeptic sj^mptoms, gastralgic attack:, and hemorrhage. One must differentiate these ulcers from disease of the bile-passages, from pancreatitis, from gastritis, peri- gastritis, gastralgia, and appendicitis, with all of which conditions peptic ulcer may be associated, and from which it cannot alwaj-s be distin- guished. In diseases of the bile-passages pain is more constant and acute, is longer continued, and is not likely to be associated with vomiting on the ingestion of food. The same statement is true of pancreatic disease. In gastritis pain is less constant; it does not come on at such regular periods, nor is it so commonly associated with and relieved by vomiting. Gastralgia is relieved by ingested food. A chronic appendicitis may cause obscure gastric sj-mptoms suggesting ulcer^s^-mptoms of "dys- pepsia," belching of gas, and distaste for food; but the characteristic pain and vomiting rareh" are present. Acute perforating duodenal ulcer pours out chyme into the light flank and appendix region, setting up an acute peritonitis throughout that area. It is a common error to mistake perforating duodenal ulcer for acute appendicitis. Prognosis. — The prognosis of acute ulcer is good, generally, if rest and dieting be observed. The prognosis of erosions is good also, with the same proviso; but the prognosis of chronic ulcer is not so favorable, and the statistics of the Massachusetts General Hospital show that about 50 per cent, of chronic ulcers are either not cured b}- medical treatment or that, if sj-mptomatically cured, the}' recur. Treatment of Peptic Ulcer. — When you have to deal with a patient the subject of an obscure chronic '' ch'spepsia " which has withstood intelligent medical treatment for a year or longer, you are fairly safe in assuming that the trouble is one of mechanical damage, and that a surgical operation on one or more of five organs will bring relief — on the stomach, bile-passages, pancreas, kidney, or appendix. Every case of peptic ulcer should have the benefit of an expert internist's opinion and proper intelligent medical treatment, which, in 134 THE AHDOMEN general terms, consists of rest and cleanliness for the organs concerned. Rest is obtained by the use of light liquid diet or rectal feeding. Clean- liness is maintained through abstinence from food and by gastric lavage. The surgeon also in his treatment aims at rest and cleanline.ss, and attains these by supplying the laboring organs with additional and competent drainage — drainage into the intestines at a point below the pylorus. Such drainage is secured through the operation of gastro- enterostomy or through Finney's pyloroplasty. Methods of gastro-enterostomy are various. Suffice it here to say that two general methods are in common use — anterior gastro-enter- Fig. 63. — Diagram illustrating anterior gastro-entero.stomy. between proximal and distal coils (Gould). Jej unoj oj unostomy ostomy and posterior gastro-enterostomy. Anterior gastro-enteros- tomy is secured by bringing up a loop of the jejunum in front of the omentum and forming an anastomosis between it and the stomach at the lowest point available in the latter organ — generally near the pyloric area. Posterior gastro-enterostomy is preferable. I need not here go into a discussion of the long-loop and no-loop operations, and of entero-enterostomy with or without division of the afferent loop. Excellent present-day opinion favors the no-loop operation of Mayo, by which an anastomosis is made between the lowest portion of the PEPTIC ULCER 135 stomach and the jejunum, where it Hos behind the stomach, three or four inches from the end of the duodenum or Hgament of Treitz.^ Finney's operation is often applicable to gastric ulcer when it can be done without opening into the ulcerated area. It gives admirable physiologic drainage. The after-treatment of these cases is extremely simple. Generally, convalescence begins at once. With the cessation of ether vomiting patients may be given water by the mouth; albumin-water and thin Fig. 64. — Posterior piastro-enterostomy. The clamps have boon ajipliod about 3 inches distal to the duodenojejunal flexure. The blades of the stomach clamp have been placed obliquely (Moynihan), while the handles point to the patient's right shoulder (Mayo, Munro) (from Gould, drawn according to the suggestions from W. J. Mayo). soup after twenty-four hours, a full liquid diet after forty-eight hours, and a carefully prescribed full solid diet by the seventh day. Con- valescence is quick, and patients may be up and about in the second week. The modus operandi of the cure of ulcer by these operations is an interesting problem, the probability being that the additional drainage 1 1 refer the reader to the text-books on operative surgery for details of these elaborate stomach operations, especially Moynihan's Abdommal Operations, and Surgical Aspects of Digestive Disorders, by J. G. Mumford. 136 THE AUDO.MEN Fig. 65. -Finney's ga.stroduodeno.c:tomy. Cross-section of pylorus and duodenum before operation, for comparison with Fig. 70 (Goukl). Fig. 66. — Mobilization of tlie second portion of the duodenum (Finney). Note vertical peritoneal incision parallel to and to tlie right of the second portion of the duodenum. The duodenum is being shelled out with the finger. Also note the dotted line on the edge of the lesser omentum. A superficial cut through the omen- tum at this point allows the pylorus to drop down, thus assisting in the mobilization of the duodenum (Gould). relieves the diseased area of a constant irritation and allows healing to take place rapidly. Fig. 67. — Gould's modification of Finney's operation. Note application of clamps. On the stomach they are placed parallel with the greater curvature, thus controlling the hemorrhage from the vessels which are seen crossing line of future incision. Inner jaws of both clamps touch at the pyloric angle. When the handles are brought together, the pyloric angle (P) is put on the stretch. It can be seen that the use of guides is unnecessary to make the folds lie side by side (Gould). Fig. 68.— Gould's modification of Finney's operation. Clamps now side by side. Folds approximated by a continuous seromuscular stitch. Stomach incision to mucous membrane; duodenum then opened freely to pyloric angle. Scissors now cutting out redundant mucous membrane at dotted line. The next step is to sew X to X, beginning at the pyloric end of the tongue (Gould). 138 THE ABDOMEN _^xs^u} Fig. 69. — Gould's modification of Finney's operation. Tongue now closed over by continuous stitch wliich has turned corner to finish front of suture, bringing x to x; (T) sewed over tongue. The line of suture is finally buried by a seromuscular stitch (Gould). $to- Fig. 70. — Finney's gastroduodenostomy. Cross-section after operation, show- ing increase in caliber of pylorus; caliber increased over Fig. 69 by length of sewed edges (Gould). I cannot recommend excision of the ulcer as a routine measure. Rarely, it may be deemed necessary. PYLORIC OBSTRUCTION 139 PYLORIC OBSTRUCTION Pyloric obstruction is one of the most important complications of ulcer. It is due commonly to cicatricial contraction of ulcer of the p}'loric portion, as I have explained already, and the obstruction may be very slight or complete; but even when slight, its effect upon the stomach and the stomach's mechanism is marked and disastrous in the long run. There are other causes of pyloric stenosis, such as neo- plasms— benign and malignant — pressure from without, crippling extensive adhesions, and the dragging of a prolapsed stomach, causing a kink at the pylorus. Whatever the cause, the stomach will eventually become thinned and distended. If it contains comfortably more than 40 ounces of water, it may be regarded as a dilated stomach. Pyloric obstruction of infancy is congenital or is acquired early. Fig. 71. — Operation of Roux completed (schematic). The symptoms of pyloric obstruction are properly those of gastric dilatation. An uncomplicated obstruction rarely gives rise to symp- toms. Obstruction with dilatation quickly becomes associated with gastric stasis — that is to say, ingested food remains in the stomach longer than normal. If one removes with the stomach-tube the stomach- contents eight hours after the patient has taken a full meal, one should find no trace of food if the stomach be normal. Food found after eight hours signifies delayed motility or stasis, and the symptoms are due to this stasis. The picture is a complicated and distressing one. The patient becomes emaciated, is troubled with pain coming^ on three or four hours after eating, has more or less vomiting, the vomitus varying in amount according to its frequency, and at times— perhaps once in three or four days or perhaps very rarely — he vomits enormous 140 THE ABDOMEN quantities of food. Ho is troubled with thirst, constipation, heart- burn, and heiuhiche. An inijxjrtant sifrn is visible ijcristalsis. Often a distinct splashing is heard if the examiner shakes the abdomen with his hand. The urine is scanty, the tongue dry and parched, and the urgency of the condition may vary all the way from a state of mild "dyspepsia" up to impending death fi'om starvation. The treatment of ])yloric obstruction should be operative in the case of persons able to submit to operation and desirous of regaining permanent health. On the other hand, palliative treatment only may be pcrmissil3le, and palliative treatment often relieves and seems at times to cure. Palliative treatment consists in lavage of the stomach, careful feeding, and the prescribing of tonics and laxatives. Un- Fig. 72. — Roux's operation complete (Moynihan). fortunately for the outlook of patients who depend on palliative treat- ment, we cannot prevent the frequent implantation of cancer upon the site of an old ulcer, whether healed or unhealed. My recent studies in the after-history of these cases at the Massachusetts General Hospital has shown that a majority of persons with stomach dilatation, when untreated, die within a few years ; that a small percentage are relieved, and that a still smaller percentage (12 per cent.) recover. Surgical treatment of pyloric stenosis is by gastro-enterostomy. by Finney's pyloroplasty, or by pylorectomy. Gastro-enterostomy is best performed by the no-loop method, and is generally satisfactory. How- ever, in the case of a greatly dilated stomach the new stoma may be dragged upon as the stomach retracts, so that one may sometimes HEMORRHAGE 141 prefer to do the operation of Chaput or that of Roux, as shown in the accompanying cuts. If the stomach and duodenum are not too much tied down and buried in adhesions, Finney's operation is extremely satisfactory. In any case of doubt as to the nature of the obstruction, especially when a considerable indurated mass is felt, one should suspect malignant disease and should perform pylorectomy. For congenital or infantile pyloric stenosis gastro-enterostomy is the only cure.' The after-history of these obstruction cases, when treated by ap- propriate operation, is exceedingly satisfactory, but I cannot too earnestly caution the student and practitioner against indiscriminate and routine operating. Every case should be treated on its own merits and according to the nature of the mechanical derangement, otherv\dse the practitioner may be distressed to find that his patient is not benefited and that the old symptoms return after a short time. In no class of cases more than in stomach disorders is a careful and thorough study of conditions demanded, and no man should presume to take up this line of work unless he has attended the surgical clinic of an expert and has practised the operations upon the cadaver or upon living animals. HEMORRHAGE Hemorrhage from peptic ulcers may be demonstrated by finding stomach blood — vomited or expressed — or blood in the stools. There are numerous causes for gastric hemorrhage besides gastric disease; among such causes are diseases creating venous stasis, such as cardiac, renal, and hepatic disorders, as well as rare cases of angioneurotic edema and aneurysm. But it is gastric disease with which we are now dealing — with gastric ulcer and gastric cancer. I have spoken of the varieties of bleeding from gastric ulcer. There is the bleeding from acute ulcer and from chronic ulcer. Hemorrhage from acute ulcer rarely is persistent or extremely grave, though there are exceptions to this rule. Hemorrhage from chronic ulcer may be slight or over- whelming. The phrase "acute bleeding ulcer" is used, but it is a mis- leading phrase, since it seems to imply active hemorrhage from an acute ulcer, whereas the condition is more frequently found to be an active hemorrhage from a chronic ulcer. When the first evidence of ulcer is a sudden hemorrhage, however, the chances are that the ulcer is acute. The Massachusetts General Hospital records show a total mortality from stomach hemorrhage of 3.7 percent. — males, 17 per cent., females, 1.27 per cent. Moreover, it appears that lethal hemorrhage is much less common in the young than in the middle aged, and less fatal in acute ulcer than in chronic ulcer. This 3.7 per cent, is a low" mortality from hemorrhage. Other statistics give the death-rate as 8 per cent. The treatment of hemorrhage is an intricate and interesting ques- tion. In general terms it is fair to assume that acute ulcer hemor- 1 C. L. Scudder, Boston Med. and Surg. Jour., 1907, vol. clvii, p. 321; and 1909, vol clx, p. 273. George Thompson, Surg., Gyn., and Obs., 1906, vol. iii, p. 521. F. E. Bunts, Surg., Gyn., and Obs., 1908, vol. vi, p. 663. 142 THE AIJDOMEV rhage may be subdued by rest and rectal feeding, while chronic ulcer hemorrhage, though it may be allayed for a time, is likely to recur after such internal treatment, and, therefore, recjuires a surgical operation for its permanent cure. Moreover, in those rare eases of hemorrhage which is persistent and brings the patient to a low ebb, an operation must be done immetliately to save life. The surgical treatment of hemorrhage from gastric ulcer is gastro- enterostomy. Other methods have been tried, but rareh- have proved successful. Excision of the ulcer or ligation of the bleeding point is not to be recommended as routine. Time is lost by such measures, and the bleeding vessel is not always found. Gastro-enterostomy, by one of the methods already described, is quick and reasonabl}' safe. The ulcer is put at rest, the bleeding ceases shortly, and convalescence generally is assured. Some care in feeding is required aftei-ward, and' if the patient's strength will permit, nutrient enemata will be employed for five or six days. The same rules apply to bleeding duodenal ulcer. PERFORATION Perforating peptic ulcer, whether acute or chronic, must be treated surgically. Though spontaneous cures are recorded, the}' are too rare to be anticipated in any given case. The symptoms of acute perforation are: sudden pain, acute localized tenderness, a falling and, later, a rising temperature, a rapid and com- pressible pulse, peritoneal facies, and vomiting generally. In other words, the symptoms are quite similar to those of perforative appendi- citis, except that the pain and tenderness are commonly located in another region. These cases, if untreated, go on to a diffuse peritonitis which kills the patient. The treatment is by early operation. Recoveries are rare after eight hours have passed wdthout such treatment. Open the abdomen through the right rectus muscle, above the umbilicus. Find the per- foration, and sew it up with Lembert stitches. Wash out thoroughly the abdomen with salt solution, and drain the wound with gauze. The ulcer will heal usually if death from peritonitis does not supervene. In the after-treatment the semirecumbent position aids drainage, which should be supplemented further by a proper wick passed into the pelvis through a suprapubic stab-wound. DISTORTION OF THE STOMACH Distortion of the stomach (hour-glass stomach) may be regarded as an analogue of pyloric stenosis. In other words, the conditions which cause pyloric stenosis may exist elsewhere in the stomach and may narrow its lumen. There may be one or more constricting cica- trices, so that the stomach is thrown into two or more pouches. Until recently it was beheved that many cases of hour-glass stomach were congenital. Further study convinces us that congenital hour- glass stomach is rare, if, indeed, it exists at all. Most of the cases GAS'];HIC ADHESIONS 143 investigated show that the deformity is due to cicatrices following an ulcerative process. The symptoms are prolonged ''dyspepsia," pain and tenderness, pain relieved by vomiting and malnutrition, frequently associated with pronounced nervous symptoms. The diagnosis is difhcult. Sundry maneuvers are advocated for demonstrating and making prominent the various pouches. Wash out the stomach until the water returns clear. If a gush of foul fluid follows later, it comes from a probable second pouch. Another test advocated by Moynihan is to map out the stomach resonance and then give a Seidlitz powder in two portions; after twenty or thirty seconds an enormous increase of resonance will be found in the upper pouch of the stomach. Later, the lower pouch will become distended. In spite of such ingenious tests, hour-glass stomach is often overlooked until it is revealed by operation or at autopsy. The treatment for hour-glass stomach, hke the treatment of pyloric stenosis, is palliative or operative. We need not consider palliation here. Operation generally cures. There are two excellent methods. If the cicatricial tissue be not too abundant, a gastrogastrostomy may be done by Finney's method, or by overlapping and forming an anastomosis between pouches. In other cases, where the distortion and surround- ing adhesions are extensive, gastro-enterostomy may be necessar}', and in such case the surgeon must form an anastomosis between the jejunum and each stomach pouch. GASTRIC ADHESIONS Gastric adhesions are a frequent complication of gastric ulcer. They are present in nearty 40 per cent, of all ulcer cases, and are a common cause of distressing symptoms. They distort the stomach; they fix it in abnormal positions; they delay its motility, and they interfere with the action of neighboring organs. Frequently they are accompanied by suppuration and burrowing fistulse. The}^ are due to the extension of inflammation from gastric ulcer, — the most serious forms of adhesions, — or to a peritonitis spreading to the epigastrium from elsewhere in the abdomen — perhaps from the appendix or Fallopian tube. An inflamed gall-bladder may become adherent to the stomach and a gastrocystic fistula form. In like manner fistulse may connect the stomach with the transverse colon, the duo- denum, or the pancreas. The sjrmptoms of gastric adhesions, or perigastritis, are as manifold as are the pathologic conditions, and the symptoms are extremely puzzling. Nearlj^ alwaj^s there are ''dj'spepsia," indefinite pain, and occasional vomiting. The chemic output of the stomach may be interfered mth, and digestion may be long delayed. Sometimes bile is vomited; sometimes there are recurring attacks of intense colic. The surgical treatment of gastric adhesions, granted the patient comes to surgery, is often difficult. If the adhesions are light and 144 THE ABDOMEN easily broken down, permanent relief may follow their separation. On the other hand, if heavy bands, with fistula' and involvement of other organs, exist, the best treatment is gastro-enterostomy to facilitate stomach drainage. GASTRIC TETANY Gastric tetany is occasionally seen, but is more often overlooked. In every case of tetany one should think of the possibility of pyloric obstruction. Gastric irritation is a common cause of convulsions in children; it may cause convulsions in adults, and such tetany is some- times associated with pyloric stenosis. The spasms are due probably to the absorption of some poison from the dilated stomach, with an associated painful contraction of the pylorus. The treatment is directed at first toward relief of the stomach by lavage or induced vomiting. Often lavage is difficult or impossible because the attempt to pass a stomach-tube excites renewed spasms. Permanent cure may be obtained by Finney's operation or by gastro- enterostomy. GASTRIC CIRRHOSIS Gastric cirrhosis deserves mention, though it is a rare condition. The disease is chronic, and does not appear to be associated with ulcer or cancer. The stomach-wall is found thickened, often seared and stenosed, and the symptoms resemble those of long-standing ulcer, except that the vomiting is small in amount. Patients die of the disease unless reheved by operation. Gastro-enterostomy has improved the condition, though the reason for such improvement is not im- mediately apparent. SPASM OF THE PYLORUS Spasm of the pjdorus (Reichmann's disease) is a rare condition, unassociatcd with obvious pathologic changes. It is said to be due to gastric hyperchlorhydria. Often it will be relieved by lavage and dieting. Should these fail, Finney's operation is a rational method of cure. GASTROPTOSIS Gastroptosis, or dislocation downward of the stomach, is commonly associated with dislocation of the colon and right kidney. The pro- lapsed stomach is often dilated also, since dragging on the fixed pylorus kinks and narrows the gastric outlet. The greater curvature may be found on a level with the navel, or as low as the pubes even, and the diagnosis of ptosis is confirmed by dilating the stomach with air or water, and finding its upper border low in the epigastrium. In such case the pulsation of the aorta may be felt easily in the epigastrium. In addition to such general treatment as I shall describe when deal- ing with visceral ptosis as a whole one may practise a variety of surgi- cal procedures for the prolapsed stomach. I have been satisfied in CANCER 145 two cases with Bcyca's operation of reefin<^ the gastrohepatic omentum, while an independent or supi)lementar3' gastro-enterostomy is of value also. In two other cases of gastroptosis with dilatation 1 have found Finney's pyloroplasty to relieve the symptoms. STENOSIS OF THE PYLORUS Hypertrophic stenosis of the pjdorus is a condition occasionally seen at autopsy and upon the operating table. It is associated with gas- trectasis, but there is no connective-tissue development. Micro- scopically, the condition is found to be hypertrophy of the muscularis and submucosa of the pylorus. It has been suggested that some of these cases may be congenital, as the same condition is found also in infants. Treatment is by Finney's operation or by gastro-enterostomy. FOREIGN BODIES Foreign bodies may pass through the esophagus and lodge in the stomach, though commonly, if they pass the cardia, they escape through the pylorus. The victims of this accident are generally children, insane persons, or drunkards. One sees lodged in the stomach such articles as pins, safety-pins, shot, coins, plates of false teeth, hat-pins, pebbles, masses of hair, nails, screws, pieces of broken glass, etc. In the case of a juggler, I have seen incredible numbers of metallic objects removed from the stomach. Dr. T. F. Harrington, of Boston, tells me that he saw a soldier, returned from the Spanish War, who was treated for sundry wasting diseases without avail; at the end, in a fatal and only hemorrhage, the man vomited a hzard. If the foreign bodies do not pass, they may remain indefinitely in the stomach or may give rise to pain, vomiting, and other " dyspeptic " symptoms. They may cause ulcer; they may perforate the stomach. Most of these objects may be encouraged to pass on with the fecal stream, but cathartics should never be employed. Our endeavor is to incrust the foreign bodj' with some non-irritating food, so as to prevent its perforating the viscera or doing other damage. Give a diet of bread and milk or Indian-meal mush, or mashed potatoes, for several days, and follow this with a mild laxative. In rare cases', W'hen there has been long-standing retention of the foreign body or evidence of perforation, one must operate. Not long ago I saw a colleague cut down upon a stomach from which an eight-inch hat-pin protruded and penetrated the liver. The head of the hat-pin prevented the pin's complete exit from the stomach. CANCER Cancer, next to ulcer, is the cUsease of the stomach which interests us most. Gastric cancer is extremely common. According to the figures of von MikuHcz and Mayo, one-third of all cancers are found in the stomach. We were formerly told that it is a disease of sudden 10 146 THE AH DOMEX onset, coming on often in persons of previously good health and strong digestion. On the contrary, we believe to-day that cancel- frecpiently develops at the end of a long course of "dyspepsia," Ijeing inii)lanted upon ulcer or the sequela? of ulcer. Competent writers go so far as to say that 00 per cent, of all cases of gastric carcinoma may be traced to pre- existing ulcer. Cancer of the stomach is nearly always primary, those gastric ulcers which are secondary being traceable usually to primar}' esophageal cancer. Metastases from gastric cancer are fouud in the lymph-nodes, along the lesser curvature, in the live)-, in the pancreas, Fig. 73. — Lymphatics of tiie stomach. and in other more distant organs. Bear in mind that enlarged nodes along the greater curvature suggest pjdoric ulcer, while enlarged nodes along the lesser curvature suggest pyloric cancer. The location of cancer in the stomach is in the pyloric region in about 70 per cent, of the cases; on the posterior surface in about 4 per cent.; cardia, 9 per cent.; greater curvature, 4 per cent.; anterior surface. 3 per cent.; fundus, 10 per cent. The ratio of men to women is about as 7 is to 5. The common varieties of gastric cancer are the cylindric-celled adenocarcinoma and the encephaloid or medullary carcinoma; next in frequency is scirrhus, and then colloid cancer. CANCER 147 Marked gastric changes take place in the presence of cancer, depend- ing upon the location of the disease. When the cancer is at the pylorus, it causes a thickening of the stomach-wall in the pyloric region and a gradual closing of the outlet, associated first with hypertrophy of the fundus and then with its dilatation. When the cancer is not at the pylorus, it may involve considerable areas of the gastric wall and cause marked deformity and crippling of the organ, with frequent adhesions to the neighboring structures and direct extension of the disease to those structures. Perforation into the peritoneal cavity, followed by a diffuse peritonitis, is a not infrequent occurrence. In regard to metastases, remember that in from 4 to 10 per cent, of the cases no metastasis has been found, the enlarged nodes present being shown to be hyperplastic merely; that the fundus is rarely the seat of carcinoma, and that its lymphatic nodes seldom are involved. The symptoms of gastric cancer are either latent or pronounced. In a great many cases we hear a story of long-continued "dyspepsia" merely, with a certain amount of heartburn, distaste for food, especially for meat, and sometimes a craving for highly spiced food. Such symp- toms may exist for many months without exciting the patient's suspi- cions. There is generally an associated loss of weight and strength, with anemia, and possibly an irregular temperature, with occasional chills. In a certain proportion of cases free hydrochloric acid is de- creased or lacking in the stomach-contents, while lactic acid and putre- factive organisms are found; blood in abundance or in mere traces may be present, and late in the disease the Oppler-Boas bacillus (a club- shaped organism). Indican is often increased in the urine, and in about one-third of the cases there is albuminuria with casts. Frequently there is edema of the feet and legs and of the abdominal wall even. The bowels are nearly always constipated. In marked cases pain, hemorrhage, and vomiting are the impor- tant symptoms, though all these symptoms may be absent throughout the disease. . . The diagnosis of cancer of the stomach is extremely difficult m its early stages. But, given a patient of middle age, with prolonged "dyspepsia," distaste for food, occasional attacks of epigastric pam, and wasting, one should suspect cancer. If to these symptoms bloody vomiting be added, and if a mass can be felt in the epigastrium, the diagnosis of cancer is almost assured. But we must not wait for these late manifestations in order to confirm the diagnosis. If we are^ m doubt, and if the patient's strength will permit, a rapid exploration should be undertaken early to ascertain the exact condition. Treatment.— Cancer of the stomach is a surgical disease, as is cancer elsewhere. No so-called medical treatment avails for a cure. It may well be that the patient and his friends prefer mild measures and a waiting for death. That is at their own discretion. There can be no doubt that cases of advanced cancer are incurable by surgery, and the kinder course is palliation, but accumulating experience shows that in the early stages of gastric cancer, extirpation of the chsease, by 148 THK AHDO.MKX a t'omj)ot(Mit surucon, will cure a jioodly propoilioii of })ati('iits, or, more often, will post])onc for years the inevitable eml. It was formerly said that the fin(lin.i>; of a tumor eontraindicated gastrectomy. On the conti-ai-y, the finding of a tumor may be cause for hope from gas- trectomy. A small tumor of the anterior j^yloric region ma}' be felt and excised and the patient recovei', while a large and extensi\'e growth on the posterior wall of the stomach may run its course, without detec- tion, to a fatal termination. Should the patient elect to have no operation done, wv must strive to make him comfoitable with gasti-ic lavagx;; with small and fre(|uent feedings of easily chgested food, es]jecially milk; with gradually ascend- Fig. 74. — Sliowing ligation of gastrohepatic omentum and superior vessels in such manner as to leave all the lyni})h-nodes attached to the part of the stomach to be excised; also lines of division of duodenum and stomach (after ^^'. J. Mayo, Ann. Surg.). ing doses of the compound tincture of iodin (beginning with 5 minims) ; with morphin for pain; and with other remedies to meet the conditions which arise. The symptoms vary with the location of the disease. Cancer of the fundus may cause no symptoms other than anorexia, wasting, and debility; cancer of the pylorus may cause the most dis- tressing symptoms — intolerable pain, vomiting, and constitutional exhaustion leading to early death. In such cases the physician is driven to the constant use of morphin. There are operations other than gastrectomy for cancer of the stomach. There are radical operations and palhative operations, and the choice depends upon the site and extent of the disease. We excise cancer of the stomach when the growth is small, the lymphatic connec- CANCER 149 tions but slightly involved, and when no metastasis exists. We perform palliative operations to relieve impending starvation, and for pain and vomiting. The radical operations are pylorectomy, partial gastrectomy, and total gastrectomy; and the difficulties of these operations are in the same order. Practically, however, a mere pylorectomy is of little service in cancer, because it is not radical enough. Partial gastrectomy is the more common and satisfactory operation. The mortality varies between 8 and 50 per cent., but as we are getting these cancer cases earlier, we are securing a lower operative mortality and an increasing number of permanent cures. The accompanying cuts (Figs. 74-77) illustrate the operation which I have been using. It is the operation described and advocated by W. J, Mayo in 1904. Fig. 75. — Showing methods of excision. Note that all the glands in the greater curvature are removed in every case (after W. J. Mayo, Ann. Surg.). Open the abdomen through the right rectus muscle, and turn out the stomach and omentum. Tie off the gastrohepatic omentum close to the liver, thus opening widely the lesser omental cavity and mobiliz- ing the pylorus. Pack off with gauze the entire area exposed. Then tie the four important arteries, two above the stomach and two below it. The gastric artery is best secured at once by double ligature where it joins the lesser curvature, about an inch below the cardia. The superior pyloric artery, a branch of the hepatic, is tied just above the pylorus. To get at the tv/o lower vessels, pass the left hand into the lesser cavity behind the pylorus, find the gastrocolic omentum, and raise it from the transverse mesocolon; then isolate and secure from the front the loU THK AHDO.MKX right gastro-epiploie artery. Next tie the loft p;astro-o])ij)loif' artory at a suitable point on the greater curvature, and tic in sections and cut away the gastrocolic omentum, taking great care not to interfei'e with the middle colic arter}', which runs in the transverse mesocolon. It is a simple matter now to remove a ])orti(jn of the st(jmach: double clamp the (.luodenum, and divide it with the cautery bcjtween the clamps. Then turn in the distal stump of duodenum. Cut off the superior portion of the stomach in much the same fashion, thus: gi'asp the viscus with a rubl^er-guarded holding clamp, and about half an inch below it j)lace a strong ])iting-clamp, to prevent leakage. Then cut off with the cautery the stomach between the two clamps and turn Fig. 76. — Showing closure of cut duodenal end by circular suture, and first row of sutures being j)Iaced on the stomach side (after W. J. Mayo, Ann. Surg.i. in the gastric stump. We have now an isolated stomach pouch and an isolated intestine to be connected. Various methods of making this connection have been devised. The so-called Billroth's first method consists in uniting the stump of duodenum with the lower angle of the gastric stump, but this method forms an insecure joint and is now little used. Kocher inserts the duodenal stump into the posterior wall of the stomach — an excellent procedure. Billroth's second method — the method employed by Mayo — consists in performing gastrojejunostomy. With a little practice, and in case the stomach is freely movable, one may perform the whole operation of gastrectomy rapidly, and the shock is less than one might expect. In fairly vigorous patients re- action from the operation is rapid. After three days of rectal feeding CAXCKll 151 careful li(iui(l nourishment may be given by mouth, and by the end of two weeks a fairly full diet with caution may be prescribed. These patients should Ix; instructed, however, that they must never indulge fully their vigorous appetites, and should always follow a careful dietar}'. Kemoval of the whole stomach, with a mortality of about 39 per cent., has been performed some 50 times. So far as the latest statistics go, it appears that about 15 per cent, of the cases have been cured permanently. The patients, if they survive the operation, show a surprising increase in weight and strength, and get along in a fairly satisfactorv manner so far as their digestions are concerned. Fig. 77. — Showing completed operation (after W. J. Mayo, Ann. Surg.). There are two commonl}' recognized palliative operations for cancer of the stomach — gastro-enterostomy and gastrostomy. The mortality from gastro-enterostomy for malignant disease is higher than the mor- tality from gastrectomy even — not that gastrectomy is a less severe operation, but because gastro-enterostomy is performed in the more grave and hopeless cases, on persons greatly reduced and with low resisting powers. Gastro-enterostomy is applicable to patients suffer- ing from pyloric obstruction, and to these only. When the cancer is in the fundus of the stomach and the pylorus is not involved, gastro- enterostomy is useless. Gastro-enterostomy is a makeshift at the best. Frequently, after submitting to it, patients improve for a time and are greatly more comfortable than before. They gain in strength, flesh, and vigor, and may get about their work. The average length 152 THK ABDOMEN of life aftor gastro-onterostomy fur cancer of the stomach is fourteen months. In advanced cancer cases, with their extensive and cripphng adhesions, posterior gastro-enterostomy rarely is aj^plicable. The routine operation is anterior gastro-enterostomy, performed by suture. Gastrostomy, or sometimes jejunostomy, is used in the case of extensive cancer of the fundus of the stomach, or when the cardia is obstructed by disease. The purpose of the oi)eration is palliation merely, in order to ward off starvation. It has no effect on pain or vomiting except in Fig. 78. — Gastrostomy — Witzel's method (Keen's Surge rjO- so far as it removes irritating food fi-om the immediate neighborhood of the growth. The viscus to be opened is drawn up to the surface, and a ru])l:)er tube or catheter is inserted, after the manner of Kader or Witzel. The viscus is then attached to the abdominal wall, and the tube is left pro- truding. Through the tube food is introduced at will. After two weeks the tube may be removed permanently. A fistulous tract is left through which a tube may be reinserted and food poured in at any SARCOMA OF THE STOMACH 153 time. The nature of the operation, if performed correctly, is such that a valve-like obstruction exists in the fistula, and the stomach-contents are retained by the closed valve between feedings. By means of this operation a patient's life may be prolonged many months. Besides cancer, the stomach is occasionally the seat of other tumors, both malignant and benign. Benign tumors make little trouble unless Fig. 79. — Feeding by gastrostomy. they obstruct the pyloric outlet, and they need not concern us further. They are rare. Of the other malignant tumors, the only one of im- portance is sarcoma of the stomach. SARCOMA OF THE STOMACH This disease has all the clinical characteristics of cancer of the stomach, and cannot with certainty be differentiated from it. Ana- tomically, it is found at the pylorus less frequently than is cancer — that is to say, about one-fourth of the sarcomata are pyloric. Generally, sarcoma involves the posterior wall and the greater curvature, arising in the submucous coat. Whereas cancer is more common in men than in women, sarcoma is equally common in both. It grows to a large size often before killing the patient, and the tumor may be seen actually distending the abdominal wall. Hemorrhage is not common; pyloric 154 Till-: AUDO.MK.V stenosis is not common; metastases are raic The disease is rai)i(l, and usually kills in iVom ten to eleven months. The onl}- treatment is by operation, as in the case of cancer — gastrectomy or gastro-enterostomy. WOUNDS OF THE STOMACH Wounds of the stomach ha\e been considered alreatly in part under the captions Wounds of the Intestines and Foreign Bodies in the Stom- ach. The history of the injury often gives little indication of the extent of the visceral lesion. Damage is inflicted by blows, crushes, and })enetrating missiles or stab-woimds. The stomach is rarely ruptured by blows or crushes. The commonest injuries are bullet-wounds and stab-wounds. The stomach differs from the intestines in being a thicker-walled organ, with muscular layers so arranged that they are less liable to allow the escape of gastric contents than is the intestinal wall to allow the feces to escape. The symptoms of wounds of the stomach are : acute localized pain, vomiting. — sometimes bloody, — and collapse, with rapid pulse and a falling, followed by a rising, temperature. Later the symptoms of peritonitis supervene. The diagnosis is often difficult, for a penetrating wound of the stomach ma}^ exist without obvious striking sj'mptoms. The treatment is immediate exploration and repair of the damaged organ. In all cases of doubt it is the surgeon's duty to explore. The stomach must be sewed up with two rows of Lembert stitches, the abdomen thoroughly flushed with warm salt solution, and drainage established at the site of injury and above the pubes. If convalescence proceeds, the patient should be nourished by nutrient encmata for five days at least. In addition to the diseases and lesions of the stomach already dis- cussed, there are numerous rare conditions and borderland diseases with which the surgeon may occasionall}' have to deal. Such are sundr}- forms of inflammation, curious tumors, tuberculosis, and syphilis. The writers on internal medicine deal with these matters. I refer the reader to such treatises as those of Xothnagel, Osier, Wood, Fitz, and the larger systems of surgery. CHAPTER V THE LIVER AND BILE-PASSAGES The Liver In general terms it is convenient for the surgeon to regard the Uver as an accessory digestive organ — accessory to the stomach and in- testines, ^loreover, it is interesting to reflect that by far the most important portion, surgically, of the liver apparatus is the system of ducts connecting the Hver with the bowel. Not that the liver in itself is devoid of surgical mterest, but such interest is infrequent compared with interest in the bile-passages. Though diseases of the liver are common in the experience of the internist, it is an unfortunate fact Fig. SO.— Relations of liver. that, as yet, surgical therapeutics has found small place in the great field of the liver proper. There are certain liver lesions which have always belonged to the surgeon, and lately two or three other diseases of that organ have been added to this list. Abscesses, traumatic injuries, cysts, and tumors are the most important of the lesions of the Hver. long recognized as surgical. Lately, the surgeon has treated cirrhosis and ptosis. Remember how the right lobe makes up the bulk of the liver; how the left lobe stretches out to the left across the epigastrium; how the broad suspensory ligament, with its round ligament coming up from 155 156 THK ABDOMEN the navel, lies between the lobes; how the lower jiosterior j)oiiion of the right lobe is uncovered of i)eritoueuni; how the small (jvia(h-ate lobe appears in the midst on the untler surface, with the gall-bhitlder lying between it and the right lobe, while at its base lie the ducts, the portal vein, and the hepatic artery. Xormally, the liver is quite movable. It may be tipped up with the costal cartilages. Xick the suspensory ligament with the round ligament, antl you may pull the liver down. ABSCESS OF THE LIVER Abscess of the liver has gained interest for American surgeons within the past twelve j^ears, because such abscesses are common among white men in the tropics. Our military surgeons are treating tropical abscess in the Islands, and frequent cases find their way to the States. These tropical abscesses are usually single. They vary in size, but may involve a whole lobe. Organisms from the intestines enter the ])ortal circulation, and dysentery is the primary disease. Many observers have found the ameba of dysentery in the pus of these liver abscesses. Hepatic abscess sometimes follows malaria, influenza, yellow fever, and tj'phoid. Henrj' Jackson, in a resume of 17 cases at the Boston City Hospital, found that 10 of his list were due directly to a concurrent ajjpen- dicitis — an important observation of many other writers also. There- fore, staphylococci and streptococci are found in the pus, while, among other agents, are coccidia, the ray-fungi of actinomycosis, and rarely tubercle bacilli. A syphilitic gumma may suppurate, and s(H'on(lary abscesses due to echinococcus and cholangitis occasionally are found. Moreover, these abscesses may be metastatic and occur in the course of a pyemia. The course of hepatic abscess varies with the nature of the infection. Tropical abscess grows slowly; infections from the appendix progress rapidly. In general, the pyogenic organisms produce much more acute inflammations than do the other and more uncommon forms. The symptoms of liver abscess vary also with the nature of the infection. The tlisease may run its course without symjitoms. Charac- teristic fever, pain, tumor, and enlarged liver rareh' are present. The patient becomes sallow and emaciated, and lies in a doubled-up position. There is seldom any jaundice of moment. If the abscess is near the liver surface, it may cause protrusion of the skin. If it is in the center of the liver, it remains inconspicuous. Of course, rupture into the peritoneal cavity or into adjoining organs will set up additional symp- toms of greater or less gravity, depending on the locality thus invaded. None of the classic signs of abscess are to be looked for or relied upon. Fever and a high-tension, rapid pulse may or may not be present. I have found the leukocytosis varying from 7000 to 40,000. Tenderness is generally absent. The diagnosis is, therefore, extremel}^ difficult often. The condi- tion may simulate manifold disorders, such as pleurisy, subphrenic abscess, disease of the bile-passages, gastric ulcer, pyonephrosis, pan- CYSTS OF THE LIVER 157 crcatitis, or any other of the comi)lex conditions seen in the associated neighboring organs. Aspiration may fail to detect pus which is present, but do not aspirate for diagnosis. It is a risky and inconclusive maneu- ver. As with cancer of the stomach, an exploratory incision is justifia- ble and generally advisable in these obscure cases of suspected h(!patic abscess. Operate to make the diagnosis, and complete the operation to establish proper treatment. Accordingly, the treatment of abscess of the liver is operative except in the early stages of a suppurative hepatitis. Two methods of operation have been recommended: complete operation at one sitting and operation in two stages — I prefer the former. Open down upon the suspected region, wall off the Hver with gauze, open, wash out, and drain the abscess. If the Hver has become adherent to the abdominal wall, the operation is by so much the easier. Operation in two stages consists, first, in exposing the suspected area and stitching the parietal peritoneum to the hver about the lesion. Then, after ten days, adhesions will have formed, when the abscess may be opened. Under the conditions of modern technic this cumbersome procedure is seldom necessary. In the case of actinomycosis, as with actinomycosis elsewhere, fol- low the operation with medication by copper sulphate or potassium iodid. CYSTS OF THE LIVER Cysts of the Hver are variously described by writers, but you will find in practice that the echinococcus cyst alone is important. It is due to the Tsenia echinococcus, a tape-worm of 4 joints, measuring about 0.2 inch. This parasite is found in the duodenum of dogs and a few Fig. 81. — Diagram of cyst of liver. other domestic animals. The embryo finds its way into the human Hver and develops slowly. It is found surrounded by a capsule of connective tissue, within which is the cuticle of the cyst, lined with parenchyma, from the ceUs of which develop the scolices or heads of the tape-worms. These scoHces have suckers surrounded by booklets. The fully developed scolices are detached from the membrane and float free in the cavity of the cyst, which contains a clear fluid, nearly color- less. These cysts may exist undiscovered for years. They grow slowly, 158 THF, AUDO.MEM and may never cause sym])t()nis. unless, from their size, they distend the liver, press upon neighhorinji; ()r protruding mass of fat adheres to and makes traction uj)on the peritoneum, and this membrane is drawn upon to form a sac, and the sac is surrounded by fat. This method of formation is frequently noticed in umbilical herniae." The pregnant state is a frequent cause of hernia in women, but males are three times as liable to rupture as are females. Such being the causes of hernia, in general terms, it is interesting to study further certain characteristics common to all ruptures. I have spoken of herniae as reducible, irreducible, incarcerated, inflamed, and strangulated. All herniae have certain anatomic points in common also — coverings, a sac, and contents of the sac. Reducible hernia, as is obvious from its name, is a hernia the con- tents of which may be caused to return into the abdominal cavity. This state of hernia is the commonest of all. Most of the patients who consult you for rupture have these herniae which come and go. If the patient stands up and strains, a swelling will apear. If he lies down and relaxes, the swelling will disappear, or may be easUy pushed back into the abdominal cavity by taxis, as the manipulation is called. A word in regard to taxis: The student or inexpert practitioner should see taxis performed by an experienced hand if he is to realize what proper taxis means. Ordinarily, taxis is extremely simple — a small hernia can be put back readily by the patient himself; but it is in the cases of large, incarcerated herniae that the expert finds his field. Lift the hernia mass directh' upward, so that the contents of the sac tend to fall straight down into the ring. Then make the approach of the hernial contents toward the ring through a funnel- shaped canal formed by the manipulator's fingers. Usually the fingers of one hand form such a funnel, while the fingers of the other hand knead and mold the contents of the sac. Sometimes a modified Trendel- enburg position helps ; sometimes a hypodermic of morphin, or the long immersion of the patient in a hot bath before and during the manipula- tions. Femoral hernia in its early stages, and before the ring has become widely distended, offers the peculiarity of a curiously intricate canal, formed somewhat like the curl of the letter /. To reduce a small femoral hernia, therefore, the surgeon molds the contents of the sac do"^TLward, then backward, then upward. Often, by palpating or percussing the hernia, one may discover the character of the sac's contents, and will conclude that there is present a mass of omentum or a knuckle of intestine. Sometimes, when the patient consults you, you will see no hernia, even when he stands up and strains, but you will be able to detect its presence, or potential presence, by inserting a finger into the suspected ring and directing him to cough or strain, when a distinct impulse will be felt, as of a water- bag impinging on the finger. These patients with reducible hernia rarely have troublesome symptoms, the most that they complain of being distress at the hernial opening, and more or less general bellyache when the viscera protrude. Sometimes there are dyspepsia, constipa- tion, and nausea. 19(J THK ABDOMEN Irreducible hernia is anotlicr term which is sclf-explanatoiv. A patient comes to you with a ruptui'e which cannot be i-eturnecl into the abdomen, of which rupture he gives a history that it has l)een out a long time. It may be of any size — which is true also of reducible hernia — from that of a pullet's egg to an enormous sac containing most of the intestines and omentum. Thei'e are various causes for its being irreducible, the commonest being adhesions between the coverings of the sac and the sac with its contents — adhesions due to a low grade of peritonitis. Another cause is incarceration. An incarcerated hernia (or obstructed hernia) is one in which the fecal stream is dammed up and arrested when the hernia is down, so that the distended bowel cannot be returned through the ring, but the contents of the sac suffer no immediate anatomic change, because their circulation remains intact. In other words, an incarcerated hernia is not an immediate source of danger. It is a common outcome of irreducible hernia, and demands attention. It enlarges and becomes tender, painful, and dull on percussion; pressure reduces its size, but it cannot be com- pletely reduced, and it still shows an impulse on coughing. There is apt to be associated nausea, and there is variable constipation, with occasional vomiting. An irreducible hernia may become inflamed, a condition to which I have already alluded. The mass becomes hot and tender, hard and distended. It cannot be reduced, and gives rise to the same symptoms as those of incarcerated hernia, with fever in addition; but there is still an "impulse on coughing." and the constipa- tion is not absolute. With proper treatment the inflammation will subside usually, but it leaves behind it adhesions, and establishes a condition tending to subsequent incarceration and to possible future strangulation. Strangulated hernia is the most serious form of irreducible hernia with which we ha\-e to deal, and it is about the subject of strangulated "hernia that the greatest interest in hernia centers. Physician and patient alike must be taught to look toward strangulation as the pos- sible outcome of every hernia. The condition is a frightful calamity, and the danger to life is imminent. The three great surgical emer- gencies of the old writers were hemorrhage, suffocation, antl strangu- lated hernia, and of the three, strangulated hernia is still the most common and the most difficult of control. In Chapter II we studied intestinal obstruction and intestinal strangulation, and saw that strangulation may be the last and serious stage of obstruction. So in the case of hemia — an incarcerated hernia contains usually obstructed bowel — an obstruction to the fecal stream. A strangulated hernia — a hemia from which the nutrition, the blood- supply, has been eliminated — may be the end-result of incarceration. Omentum as well as bowel may become strangulated. Observe further that strangulation may take place in an old irreducible hernia, and that it may take place suddenly also in a hemia hitherto reducible, or it may be the initial evidence of a fresh hernia. One must always distinguish the elastic constriction or strangulation from fecal impac- ABDOMINAL HERNIA 197 tion or incarceration. Sti'anfiulatcd hernia occurs thus: a loop of intestine becomes crowded tlown into the sac, and when the increased amount of pressure diminishes, the hernial ring, which has been forcibly distended, contracts and grasps the loop with an elastic grip. Thus stoppage of the bowels is established, as w^ell as interference with the gut's circulation. The circulatory disturbance may be venous only, or both veins and arteries may be shut off, and, according to the degree of strangulation, the further destructive processes are slow or rapid. If the arteries are still patent, the irreducible viscera become engorged, exudation follows, and strangulation gradually becomes complete. The bow^el then becomes necrotic, often with astonishing rapidity, so that sometimes it is no longer viable after eighteen or twelve hours even. The terminal intestinal arteries do not anastomose. The lumen of the gut is loaded with active bacteria, under the most favora- ble conditions for making trouble. Much the same condition results when both veins and arteries are suddenly occluded. In either case there follow necrosis, ulceration, gangrene, peritonitis. Even if the gut be found viable at operation and be returned to the abdominal cavity, damage to its walls may have occurred in one or more places, so that later, with healing ancl scar-formation in the intestine, there may result stenosis and obstruction.^ As a rule, however, if the strangu- lation is reheved early, the intestine will recover. If necrosis supervene and surgical relief is not provided, the patient will die of shock or general peritonitis. In rare cases — about 5 per cent. — the destructive process will penetrate the sac and skin, and the patient will recover with a fecal fistula or artificial anus. The symptoms and signs of strangulated hernia are in large measure the classic ones seen in other intestinal strangulations. One finds that the hernia, perhaps formerly reducible, cannot now be replaced.^ If not recently formed, it is larger than usual, tense, firm, or even hard; without resonance, without expansile impulse (a hernia incarcerated merely expands with straining; and in this fact Hes an important distinction between strangulation and incarceration) . The strangulated hernia is painful and tender on pressure, especially at its neck. The bowels do not act, though they may often be felt contracting, and may cause colic and spasmodic pains, especially at the navel and the pit of the stomach. With this pain there are commonly some tender- ness and a feeling of tightness in the abdomen, particularly in the umbilical region, and between it and the hernia. The patient is often nauseated, and vomits nearly all the food and drink that he swallows, besides gastric secretions, bile, or the diluted contents of the small intestine. The pulse and respiration are usually quickened and rather feeble; the patient feels and looks wretched and miserable— ''anxious," as we say. He cannot sleep or eat, and the hands and feet are apt to become cold, shrunken, and dusky. 1 See important article by Percy W. G. Sargent, Ann. Surg., May, 1904. _ 2 There is a grapliic description of tliis condition in Sir James Paget s Clinical Lectures and Essays, 1875. 198 THE ABDOMEN Whenever all these things are observed, and when they remain after reasonable attenij^ts at the hernia's reduction without ojiei-ation, }'ou may hold that the operation shoukl be done without delay. Much more, if possible, should it be clone if all these phenomena be worse than I have described. When the integuments over the hernia are inflamed, thick, sodden, ruddy, or emph}'sematous; when the whole abdomen is swollen, tense, and tender; when the vomitus is like the liquid feces of the ileum; the pulse rapid, feeble, and small; the skin cold, dusky, and clammy; when the patient is dim in sense and mind or in an anguish of misery, with retching and hiccough — when all or the greater part of these elements of what the old writers call a miserere are com- bined, then, without trying any other method of reduction, you must operate instantly, though you may have only the slenderest hope of doing good, and a serious fear of seeming to do harm. The foregoing fine account of strangulated hernia is taken almost verbatim from Paget's delightful book. His description will alwaj^s apply, and there is little the modern surgeon can add for aid in the diagnosis. We note the temperature, which is frequently subnormal at first, rising as the primary shock passes and peritonitis develops. It may reach 102° or 103° F. The pulse, at first rapid, feeble, thready, becomes somewhat hard and wiry with the advent of sepsis; later it falls away to a flickering stream. There is almost alwa3's a slight leuko- cytosis— 12,000 to 20,000. The urine becomes concentrated; the tongue is dry and furred, with red cracks across it; the breath is horribly offensive. Such is the scene. We found our diagnosis on finding a hernia which is irreducible, non-expansile "on cough," and tender; on a feeble, rapid pulse; an anxious expression; a slightly chstended abdomen, tender at the navel, epigastrium, and vicinity of the rupture; on nausea and vomiting. Treatment. — Fortunately, the precision of our diagnosis does not involve so immediately the question of operating or not operating as was the case in former times. To-day one operates in all cases of trou- blesome hernia. One operates if in doubt, and solves his doubts by operating. So different is the question of the treatment of strangulated hernia from the question of the treatment of the other types of hernia that I will anticipate by discussing briefly here the treatment of strangulated hernia. In many respects the problem of hernia is like the problem of appendicitis. Like appendicitis, hernia may be chronic or acute. It may come and go. One may procrastinate for long in the treatment, using palliative measures. Either appendicitis or hernia may wake up at any moment, to become alarming and deadly. Both kill through perforation, peritonitis, sepsis. In both, when quiescent, the radical operation is easy, rapid, safe, and sure. In both, when acute, the operation is inevitable, but not always life-saving. The term "radical cure of hernia" applies commonly to the treatment-at-leisure of chronic hernia, not strangulated. Now, when we have to deal with strangulated hernia, our endeavor nmst be to avert impending death by relieving INGUINAL HERNIA 199 the stranp;ulation. After that, if the patient's strength permit, one may perform a radical cure b}' sewing up the ring. Our previous dis- cussion of intestinal strangulation and its treatment (Chapter II) applies to the matter now in hand. In a word, one cuts down upon the sac of strangulated hernia, opens it (herniotomy), and enlarges the ring so as to permit the viscera to slip back into the abdomen. Then, before replacing the viscera, the surgeon must make sure that they are viable. Obvious necrosis must be removed, even to the resection of intestine and excision of omentum; and such further steps — anastomosis, end-to-end suture (or Murphy button), or artificial anus — must be employed as the exigencies of the case and the condition of the patient will allow. The question of the viability of bowel is often difficult. Glossy, firm, purple bowel is viable. Dull, friable, black, stinking bowel is gangrenous. But there are man}- intervenmg stages. In general terms, doubtful looking gut that gradually improves in color on being released and wrapped in warm cloths may be returned. Bowel persistently dull and discolored should be excised, or at least incised for fecal drainage, and fastened into the wound for observation and further trentment. After the operation these cases demand anxious care. The questions of feeding and moving the bowels depend for their answer upon whether or not the mtestine has been injured. In general terms a vigorous patient, with viscera not wounded, may be pushed on rapidly, as after any exploratory abdominal section. But the presence of intestine wounded by resection necessitates rectal feeding, prolonged care, and such a slow convalescence as we have seen in the case of all operations on the intestines. Let us now take up in more detail the anatomy of some of the com- moner forms of hernia, with diagnosis and treatment. INGUINAL HERNIA Inguinal ^ hernia is the most frequent rupture in males. It occurs occasionally in females. There are two forms of ingaiinal hernia — the direct and the indirect. We must glance for a moment at their anatomy .2 The inguinal region, for surgical purposes, is that portion of the abdomen bounded by Poupart's ligament, the external border of the rectus muscle, and a horizontal line drawn from the anterior superior spine of the ilium to the rectus. The parietal layers here are : (1) Skin and superficial fascia; (2) aponeurosis of the external oblique; (3) the internal oblique and transversalis muscles, which are not at- tached to the injier half of Poupart's ligament; (4) the transversalis fascia; (5) the subserous connective tissue, in which lie the deep epi- gastric artery and vein; and (6) the parietal peritoneum. Layers two, three, and four are penetrated by the spermatic cord in an obfique direction. The cord lies in the inguinal canal, which is a potential passage only, not open except when distended by a hernia. The stu- * Lat., ingiien, the groin. 2 The teacher or student may use profitably D. X. Eisendrath's^models, illustrated in his paper published in Jour. Amer. Med. Assoc, March IS, 1905. 200 THK AI5D(XME.\ (lent iim.^t got clearly in hiw mind the position of the coid and its relations — that is a leading feature of our problem. The cord is always outside of the peritoneum. To trace it Inickward: it starts from the base of the bladder and, passing upward and outward, outside of the peritoneum, between it and the transversalis fascia, it turns sharply downward and forward into the internal ring, beneath the transversalis fascia and internal obli(iue fascia, which two fascia) are here linked together to form the conjoined tendon. Passing through the internal ring and the inguinal canal, which is from 1^ to 2 inches long, the cord emerges from the canal through a slit in the external oblicjue aponeurosis — a slit known as the external ring. The cord is now beneath the super- ficial fascia, and drops over the spine of the pubes into the scrotum. At the point where the cord passes the transversalis fascia the latter i— i-^ > . 3 Fig. 105. — Dissection of in^juinal canal: 1, External oblicjue, turned down; 2, internal obliqne; 3, transversalis; 4, conjoined tendon; 5, rectus abdominis with its sheath opened; 6, triangular fascia; 7, cremaster (Heath). structure .sends out a prolongation called the infundibuliform fascia, which accompanies the cord into the scrotum and forms the tunica vaginalis communis. There are two other fascia? accomjjanying the cord — structures of both anatomic and of practical surgical interest — the cremasteric fascia from the internal oblique, and the intercoluranar fascia from the external oblique. So w^e see that the cord, as it passes through the inguinal canal, is surrounded by sundry structures of varying strength. In front of it is the external oblique aponeurosis (and some fibers of the internal oblique in its outer part) ; behind it is the conjoined tendon of the internal oblique and transversalis and the transversalis fascia; within (upper wall) are the arching fibers of the conjoined tendon, beyond which lies the rectus muscle with its cover- ings; without (lower wall) is the stout Poupart's ligament. An im- INGUINAL HKKNIA 201 portant landmark is the deep epigastric artery, which springs from the external iliac, where it passes under Poupart's ligament, and mns up- ward and inward along the outer edge of the rectus muscle. The outer edge of the rectus, Poupart's ligament, and the deep epigastric artery form Hesselbach's triangle. The artery hes in the subserous connec- tive tissue outside of the peritoneum. The relation of this artery to the two rings determines direct and indirect hernia. The artery passes upward behind and between the rings. Immediately to its outer side is the internal ring, the entrance to the canal (we are looking at these structures from within the abdomen) . Immediately to^ its inner side lies the depression or fossa representing the external ring. The epi- Fig. 106. — Aponeurosis of external oblique muscle, in which is shown the external ring covered by inter columnar fascia (de Garmo). gastric vessels, therefore, form a strong ridge, on either side of which lies a weak depression. Through these weak depressions hernite pro- trude—direct hernia plunging through the wall, to the inner side of the artery, and emerging at the external ring; indirect hernia, forcing its way dowm through the internal ring and canal, in front of and across the aiiery, to emerge also at the external ring. So where they emerge the direct hernia carries before it the peritoneum, fascia transversahs, conjoined tendon, and intercolumnar fascia, much thinned, to be sure; while the oblique or indirect hernia, as it worms its way through the canal, carries before it none of these structures except the peritoneum. The nerve-supply of these parts is interesting, and it is wise to spare nerve-branches in operating upon hernia. The terminal branches of 202 THE ABDOMEN the ilio-inguinal nerve emerge at the external abdominal ring, and the hypogastric branch of the iliohypogastric perforates the aponeurosis of the external obliciue above and to the outer side of the external ring. There are three arteries — two of them important: the spermatic artery, which supplies the testicle; the artery of the vas deferens, lying in the sheath of the vas; and the cremasteric branch from the epigastric. The veins forming the pampiniform plexus make up the bulk of the cord. If you understand the anatomy of this region, the various operations appear simple enough. The diagnosis of inguinal hernia is usually easy, though occa- sionally it may offer diffictdtics. I have said that the sw^elling may disappear when the patient lies down. This fact of the disappearance Fig. 107. — Aponeurosis opened to internal ring, showing lower laorder of internal oblique muscle; transversalis fascia in deep wall of canal (de Garmo). of the swelling confirms the diagnosis of hernia. For further confirma- tion the surgeon may introduce his finger into the ring to ascertain the presence of " impulse on cough." It is not always possible to dis- tinguish direct from indirect hernia, but the practitioner should re- member that direct hernia rareh' becomes large enough to descend into the scrotum; while, on the contrary, indirect hernia may descend and cause an enormous scrotal swelling. We differentiate hernia from inguinal adenitis, which presents a hard, unvarying swelling; from inguinal sarcoma, which is hard and unvarying also; from psoas abscess, which fluctuates and may be confused with inguinal hernia; from various hard and soft tumors of the testicle and cord, which tumors are constant; and from hydrocele, which most closely resembles hernia. INGUINAL HERNIA 203 Hydrocele is fluctuant, dull on percussion, shows transmitted light when examined by the hydroscope, and is invariable in size, except, of course, in cases of congenital hydrocele, but congenital hydrocele is commonly associated with and a part of congenital hernia. The operative treatment of both forms of inguinal hernia has now been brought to such perfection that palliative measures are rarely considered by surgeons. Yet palliative measures have their value, and by palliation I mean the use of the truss. One hesitates to advise a radical operation upon a feeble old person, and one shrinks from Fig. 108.— Deep dissection of inguinal and femoral canals (de Garmo). operating upon persons with advanced organic disease — cardiac, pul- monary, renal, diabetic. Moreover, in a Hmited class of cases trusses will cure hernise— the hernia? of children under four years of age_ (the home-made yarn-truss will often suffice) ; the small recent hernise of young adults. In order to attain this result, however, you must enjom the patient to wear the truss constantly that the hernia may not come down, else a single violent exertion may undo the good work of months. The only hernise suitable for truss wearing are reducible hernise. Irre- ducible hernise are irritated and made worse by a truss. Large, irre- 204 THE ABDOMEN ducible scrotal hernisc, however, may be supported in a well-fitting bag should the radical ()i)eration seem inadvisable. There is a great variety of trusses made b}' the instrument-makers, and the principle of them JO'.l. — Truss in place. all is a stout spring-belt encircling the waist and furnished with a pad to overlie the hernial ring. These pads are made of wood, leather, cork, and similar materials, but much the most effective and comforta- Fig. 110. — Yarn-truss for congenital hernia. ble is the water-pad truss, devised by H. H. A. Beach some twenty-five years ago. A well-fitting, easy, water-pad truss will hold up an inguinal hernia perfectly, and enable the patient to lead a comfortable life and indulge in almost any form of active exercise. INGUINAL HERNIA 205 Fifteen years ago we told patients that a radical cure would give about an even chance of immunity from relapse. To-day we are justified in saying that about 97 per cent, of our cases can be cured permanently by operation. The development of the operation for inguinal hernia forms an interesting historic study, but in this place I shall limit myself to describing a satisfactory operation for each form, — the indirect and direct, — and shall refer the reader to the literature of the subject should he wish to study a variety of operations. I have before me a list of 28 men who have devised or modified operations for inguinal hernia, and with a few exceptions these operations are quite similar. All of them depend for their success upon a perfect aseptic technic, for it is since the days of aseptic surgery only that these opera- tions have proved satisfactory. Fig. 111. — Irreducible hernia (de Garmo). In operating for inguinal hernia the surgeon endeavors to meet and overcome three problems — the dealing with the sac, the dealing with the cord, and the secure closure of the canal or ring. Once it was thought that the fossa formed within the peritoneal cavity by the closed sac, after operation, gave a starting-point for recurrence, and doubtless this is true. It has been always recognized that the passage of the cord through the abdominal wall inevitably causes a weakening of the wall at that point, and this doubtless is true also. A long course of experimenting was necessary to determine just what structures in the abdominal wall should be sewed together in order to provide the strongest barrier against the recurrence of hernia. We have solved this problem and now know that stout aponeurotic tissue overlapped offers a firmer barrier than does muscle tissue. So we meet the three problems : first, by tying or suturing and cutting off the sac, and drop- 206 THE ABDOMEN ping the stump well within the peritoneal eavity at a point not weakened by the past^age of the cord, if possible. We transplant the cord, or bring it out through a new opening without transplanting it. Bearing in mind that the prime cause of weakness in the inguinal region is the lack of attachment of the conjoined tendon to Poupart's licjanient in its inner half, we make good the defect by stitching the conjoined tendon to that inner half of Poupart's ligament and to Ciimbernat's ligament — we attempt to improve on nature. Method — Oblique Inguinal Hernia. — The patient is put to bed for a couple of days before operation and the bowels thoroughly evacuated by castor oil and enemata. An oblique incision is made 5 or 6 inches long, from the pubic spine upward and outward over the course of the canal, as far as the anterior-superior spine of the ilium, parallel to and two fingerbreadths from Poupart's ligament. The external ring Fig. 112. — Incision for cure of inguinal hernia. quickly is developed with the knife and with gauze dissection, and all bleeding points are secured, that their oozing may not obscure and soil the deeper field nor favor subsequent infection. For a space of about 3 inches around the incision the superficial tissues are swept back by a gauze wipe, so as thoroughly to expose the aponeurosis .of the external oblique. This maneuver greatly facilitates the subsequent handling of that aponeurosis. The inguinal canal is then slit up with scissors, thus dividing thoroughly the external oblique and exposing the deeper parts. In doing this avoid the two nerves of the region. (Some surgeons prefer to open the external oblique aponeurosis half an inch above and to the inner side of the canal.) The edges of the opened aponeurosis are now seized, firmly retracted, and turned back from the underlying conjoined tendon with further gauze dissection. You will see that the deep parts are now thoroughly exposed down to the preperitoneal fat. The hernia bulges into the wound, its sac closely INGUINAL HERNIA 207 associated with the coverings of the spermatic cord. The sui'geon must next separate carefully the cord from the sac. One cannot always do this without tearing apart the structures of the cord, but this makes no difTerence so long as the vas, the arteries (especially the artery of the vas), and two or three good-sized veins are left. The sac is most easily separated from the cord by firm gauze dissection, and sometimes this maneuver is facilitated by opening the sac and holding it up upon the extended fingers inserted within it. The cremaster may be well de- veloped, in which case one may utilize it in closing the abdominal wound. Split it off and separate its fibers from the sac. Now tip the patient about 25 degrees into the Trendelenburg position, elevate the sac, and Fig. 113. — Oblique incision through skin and superficial fascia down to fascia of the external oblique muscle. Note the external abdominal ring, made apparent by slight bulging caused by fuU hernial sac (adapted from Scudder). return its contents into the abdominal cavity. Secure the neck of the sac with a stout catgut purse-string suture ; cut off the stump and push it back within the internal ring. The distal end of the sac may be dissected out or left, as you choose. This closure of the peritoneal sac must be made secure. If the peritoneum is thickened or is overlaid with fat, I recommend sewing up its opening with a catgut or silk buttonhole stitch rather than tying it off with a purse-string. Be sure also that the sac stump is free from all adhesions, both inside and out, that it may slip well back, freely, into the abdomen. Then to close the abdominal wall— the canal: the problem is un- like other similar problems in abdominal surgery, because the cord is 208 THE ABDOMEN in the way of a tight closure of the wound. There are two methods of treating the cord, luring it out a httle below (1 or 2 inches) the internal ring, stitch together the conjoined tendon and Poupart's liga- Fig. 114. — Oblique incision in line of fibers of the external oblique fascia. Ex- ternal oblique fascia freed from parts beneath: Note fibers above of internal oblique conjoined tendon, below well-developed cremasteric fibers, bulging sac of hernia, cord showing at inner angle of wound (Scudder). ment, and let the cord lie upon them (transplanted) with the aponeu- rosis of the external oblique stitched over it to cover it in (Bassini). Or else carry the cord to the very bottom of the abdominal wound and Fig. llS.^The sac of the hernia has been isolated sufficiently and raised by for- ceps. Note scissors opening the sac, cord in lower angle of wound (Scudder). bring it out alongside of the pubic spine; with the cord thus out of the way the abdominal wall may be sewed up as though the cord did not INGUINAL HEKNIA 209 exist. Whatever the treatment of the cord may be, you must see to it that it is not unduly pinched where it emerges through its new arti- Fig. 116. — The suture is being taken through and across the neck of the sac. Note retractor keeping internal ring region well in view. Note lifting of cord by gauze-tape (Scudder). Fig. 117. — Closure of canal (Scudder). ficial ring, and to that end it is well to thin it do^^ai somewhat if it be large. Thin it down by removing a few veins and any superabundant fat tissue. 14 210 THE ABDOMEN In sewin.ti' u]) the abdominal wall — conjoined tendon to Poupart's ligament — 1 prefer to use a mattress suture of chromic gut, or gut pre- pared by Bartlett's method. The aponeurosis of the external oblicjue is then sewed up to cover in the deep field. I emplo}- a button-hole stitch of catgut for the external oblique, and close in the skin wound with a running hoi-se-hair stitch. Eveiy student will recognize the fact that details of this method may be varied indefinitely. Some operators employ silk throughout; some kangaroo tendon; some silver or copper wire; the main principles are identical. Fig. I IN. — IlaLsted's operation. Mattrf.^s suture in eli -f eanal (Kelly). In some large hernise of long standing the conjoined tendon ma}' be so thin or nearly obliterated that it cannot be employed. In such cases Bloodgood ^ recommends making use of the edge of the rectus instead of the conjoined tendon. The rectus sheath is exposed and divided in front of the nmscle, in the direction of the muscle-fibers, upward from the pubic insertion. The muscle bulges from the cut and is caught with silk sutures. Deep stitches are then introduced, joining the rectus to Poupart's ligament. I have found this operation satis- factory in a number of difficult cases. Direct Inguinal Hernia. — As Davis' points out, direct hemiae are 1 Joseph C. Bloodgood, Johns Hopkins Hosp. Bull., 1896, vol. vii 2G. G. Davis, Ann. Surg., Januarj', 1906. INGUINAL HERNIA 211 usually seen in one of two forms. One form pushes its way through the conjoiiKMl tendon and comes out at the external rins;. This hernia is Fig. 119. — Halsted's operation. Mattress sutures tied (Kelty)- ,'>K-g: 03 Fig. 120. — Halsted's operation. Suture of external oblique aponeurosis (Kelly). covered with the structures I have already described in discussing the anatomy. The other form of direct hernia bulges around the outer or lower edge of the conjoined tendon and gradually decreases in size as 212 THK AHDO.MKN' it extends outward toward the deep ejjigastj-ic artery. In dealing with this form of direct hernia one may employ Bloodgood's rectus trans- plantation method already desci'ibed. In the case of the first form of direct hernia, the form covered l)y the conjoined tendon and other structures, Davis advises a plastic opera- tion, employing the conjoined tendon alone, and I have used this method successfully in two cases. Davis's method consists in dividing the con- joined tendon transversely and sewing it uj) by the overlapping flap method. As a general rule, however, transplantation of the rectus has proved itself a satisfactory measure in these cases also. In all these her- nia operations avoid damage to the iliac vessels, which are surprisingly near the wound. I have seen the vein pricked open. So great is the number of writer's on the subject of inguinal hernia, and so numerous are their methods, that I feel impelled to name some of them. Czerny, in 1877, closed the sac and inguinal ring. He dropped back the sac and sewed the pillars of the ring together. Kiister included the floor and wall of the canal in his operation. Championniere split up the external oblique. Hall and Barker modified the treatment of the sac by twisting it and stitching it into the wound. MacEwen does not cut off the sac, but folds it up into a pad which is made to lie in the preperitoneal space. Bassini, whose method is the basis of nearly all modern operations, employs the maneuver I have described in detail, transplanting the cord and isolating the sac at its neck, stripping it back to a distance from the ring. Wolfler has transplanted the cord bj^ passing the testicle through the space between the two recti muscles, and I have employed a similar method, passing the testicle through the conjoined tendon, but long ago abandoned it. Kocher transplants the sac entire, slipping it under the external oblique and bringing it out well outside of the internal ring. Schede buries silver wire sutures deeply. Witzel has used buried wire netting, while Trendelenburg and Kraske have made a bone-flap which is turned upward from the pubes. "\\'. S. Halsted, who shares with Bassini the honors of the best advanced work on inguinal hernia, published in 1903 an elaborate essay on his completed operation. In addition to the details I have already des- cribed, he makes a point of using the cremaster muscle to strengthen the scar in cases of long-standing and difficult hemise. He ligates the sac at the highest possible point by transfixion or by a purse-string suture, and after tying this suture, carries out both ends under the internal oblique nmscle, and passing through this muscle about half an inch apart, the suture ends are then tied. The princi])le is similar to that of Kocher. Both the deep stitches and the stitches of the external oblique are so passed as to effect an overlapping of the appropriate structures.^ Of the many writers upon the subject of inguinal hernia I mention Kingscote, Bishop, Phelps, Rotter, Frank. Ferrari, Magnai, Postenski, Girard, Coley, McBurney, Ferguson, and Fowler, whose contributions are well summed up in Dennis' and von Bergmann's Systems of Surgery. 1 Johns Hopkins Hosp. Bull., 1903, vol. xiv, p. 208. FEMOKAL HERNIA 213 The after-treatment of these cases of hernia is important. The general routine^ is that wliich follows any clean aljtloniinal section, but inasmuch as a sound closure of a rupture, long open, is essential to success, one must keep the patient in bed rather longer than ordinarily. I prac- tise rest in bed for seventeen days, then have the patient get up gradually, walk about at the end of a month, and avoid active exercise for another month. Allow him to wear a truss under no circumstances: it thins down the cicatrix and favors a recurrence of the rupture. Should the patient be very restless during the first three days and put a strain on the wound by flexing his thigh, I dress the corresponding leg in a ham splint. This immobilizes the knee and keeps the leg quiet. The best dressing for the wound is a cotton and gauze cocoon over the incision, reinforced by a heavy sheet-wadding pad held in place with a firmly applied spica bandage of Canton flannel, which should be basted over to keep it from slipping. In the case of fat persons or feeble persons, or if there be excessive postoperative oozing which cannot be checked, it is well to leave a cigaret drain in the lower angle of the wound, and remove it twenty-four hours after the operation. These general directions for after-treatment apply to both forms of inguinal hernia and to femoral hernia. Inguinal hernia in women is one of the easiest hernise to cure. The condition is not very common, and may be mistaken for femoral hernia, but a careful study of the position of the neck of the sac, and its rela- tion to the pubic spine and to Poupart's ligament, will enable the practi- tioner to distinguish the two. A large inguinal hernia in a woman will descend into and fill up the corresponding labium majus, just as the large hernia in man descends into the scrotum. In operating upon inguinal hernia in woman the question of dealing with the cord is practically eliminated. The round ligament in the female corresponds to the cord in the male. The various steps already described are followed, except that the cord need not be transplanted, but may be secured within the stitches which attach the~ conjoined ten- don to Poupart's ligament. The surgeon must be careful not to cut off the round ligament, else its stump wall slip back behind the internal ring, and by so much will weaken the uterine supports. FEMORAL HERNIA As the inguinal portion of the abdominal wall is weakened b}^ the inguinal rings and canal, so the neighboring region below Poupart's Hgament is weakened by the passage of the femoral vessels from behind the peritoneum into the thigh. A glance at the figure shows how the crural artery and vein lie in their separate sheaths, and how, between the vein and Gimbemat's ligament, there is an opening known as the fem- oral ring. This ring is patent except for a stray lymph-node, and into the ring a hernial pouch from the abdomen may protmde. This is the common form of femoral hernia, though very rarely a hernia may en- gage at some other weak point, at an opening in Gimbemat's ligament, 214 THE ABDOMEN or along the sheaths of the vessels. These femoral hemiae, when small, appear as mere bulgings h(>lo\v Poupart's ligament, but if they press on- ward, they burrow l)eneath the fascia lata until they reach the weak cribriform fascia at the saphenous opening, when they protrude beneath the falciform ])rocess antl appear as large swellings in Scarpa's triangle. The dangers and incon\-eniences of these hernial are such as I have already described. Femoral hernia is a common form of hernia in women; it is rare in men. A femoral hernia may be supported by a truss, but with more difficulty and discomfort than is the case with in- guinal hernia. The operative treatment of femoral hernia has been much debated, and sundry procedures are advocated, but, on the whole, we cannot feel sure of curing these herniae as we feel in the case of inguinal hernia?. Fig. 121. — 1, Poupart's ligament; 2, femoral ring; 3, Gimbemat's ligament. During the past five years I have used the method advocated by C. H. Mayo, Ochsner, and others, and feel that our evidence of its value is strong. Make a five-inch incision one inch below and parallel to Pou- part's ligament. Expose the sac and free it thoroughl}' well up into the abdominal cavity; open it and return its contents; then draw it down, ligate it as high as possible, and cut it olT short, leaving the liga- ture ends long. Thread each long end into a needle and pass these needles up from within the abdomen through the abflominal wall, and tie them outside of the external oblique, Ih inches above the femoral canal. This secures the peritoneal process away from the ring, and prevents the stump of peritoneum from passing into the canal during its healing. The canal is not further treated except to clear it from fat. The superficial wound down to the femoral opening is then closed with UMBILICAL HERNIA 215 catgut, except that the skin wound is sutured with superficial horse- hair. On first thought, and in view of the elaborate treatment of the canal advocated by many surgeons, this operation sounds ineffective; but, in fact, the femoral ring, relieved of the pressure of the hernia, closes down to a normal size, and relapses have been rare in a large series of cases. Here three weeks' rest in bed and the subsequent avoidance of a truss are prescribed. Of the other femoral hernia operations I mention that of Bassini, who ties the neck of the sac, cuts it off, and returns it into the belly, and then with deep sutures attaches Poupart's ligament to the pectineal aponeurosis as high up as the pectineal eminence. Kocher performs an operation somewhat similar to Ochsner's, but after exposing the sac, instead of cutting it off, he inverts it on the point of a forceps, forces it through the canal, and brings it out, apex first, above Poupart's liga- ment, where he secures it beneath the skin. He sews up the deep structures in much the same fashion as does Bassini. NicoU ^ describes an interesting and elaborate procedure: after opening the sac he splits it, twists the neck, and interlocks the two halves by buttonholing one through the other. He then reduces the sac through the ring into the extraperitoneal space, and causes it to He bunched up within the ab- domen, between the peritoneum and the transversalis and iliac fasciae, over the internal aperture of the femoral canal. He then closes the femoral ring by laying bare the pubic ramus from the femoral vein to the pubic spine, detaching the periosteum, drilling tw^o holes through the ramus, and stitching firmly with mattress sutures Poupart's Hga- ment to the ramus. In other words, he closes the femoral ring by reinforcing and extending into it Gimbernat's Hgament. Kammerer - describes a further elaborate operation advocated b}^ Lotheissen in 1898 and by Gordon in 1900; that is but another added to the Hst of the many operations proposed by many surgeons. Most of these opera- tions are designed, and rather ineffectually designed, to close the femoral canal. The simple operation I described at first, which leaves the canal to close itself, is effective. UMBILICAL HERNIA Umbilical hernia is a subject which we may divide into — (1) Con- genital hernia of the cord; (2) umbilical hernia of infants; (3) umbilical hernia of adults. 1. Congenital hernia of the cord (ectopia viscerum) is probably a malformation or monstrosity, and is due to a faulty closure of the vitel- line duct. A large part of the abdominal contents may protrude through the opening. Sometimes operative measures may reduce or improve the deformity, but the condition is rare and should be studied in the large treatises on surgery. 1 Brit. Med. Jour., November 8, 1902; Scottish Med. and Surg. Jour., December, 1903: Ann. Surg., Januany, 1906. - Frederick Kammerer, Ann. Surg., Jime, 1904. 216 THE A B DOM EX 2. Uttibilicdl hcrnid of iiifdnls is due to failure of the lunbilical ring to close tightly during the first few weeks of life. A w(>ak spot is thus left in the abdominal wall, and a small hernia may protrude, induced by the child's crying and straining. The condition is extremely com- mon in infants, but rarely results seriously, and strangulation is a remote curiosity. This hernia in infants can almost always })e cur(>d by the use of a light support, ^^'rap a penny in gauze; press it down upon the ring of the reduced hernia, and strap it into place with a six-inch strip of adhesive plaster passed over the belly. Teach the nurse to reappl}' the plaster once a week. This usuall}' will cure the hernia in two or three months. It the hernia persists as the child grows older, a specially constructed padded belt may be worn until a cure is effected. If it becomes apparent in the course of years that the ring is not closing, a simple radical operation may be done. Cut down longi- tudinally upon the hernia; reduce its con- tents ; open the sac ; free all adhesions ; loosen the peritoneum about the ring, and sew the peritoneal edges together. Then excise the ring and sew up the abdominal wall. This operation is simple and effective. The after- treatment needs no special comment. 3. The umbilical hernia of adults is a far more complicated affair and merits careful consideration. This form of hernia is ten times commoner in women than in men. Unlike the umbilical hernia of children, it may reach an enormous size — as large or \ LU/ I larger than a man's head, and the ring may \ 11 / be as much as three inches or more in di- ^ ' ameter. Women are more prone to it than men, on account of the more sedentary lives of the former and the relaxation of their ab- dominal muscles, and especially from the ab- dominal distention due to pregnancy and large pelvic tumors. The hernia grows quite rapidly. Commonly, it contains omentum and small intestine, but may contain omentum, large intestine, and, rarely, the stomach or even the utems. The cover- ings of these hernise are thin and are composed of little besides skin and superficial fascia, so that the hernial sac, protruding between the recti muscles through the umbilical ring, is close to the skin and often adherent to it. These hernise are frec[uently irreducible, but rarely become stran- gulated. Owing to the inevitable friction and irritation of the region, the sac, throughout its whole extent, may become adherent to the skin and the viscera to the sac. The treatment of umbilical hernia may be the wearing of a truss belt if the patient chooses; and, in the case of feeble, elderly persons, such palliative treatment is the only reasonable measin-e. If the hernia Fig. 122. — Diagram show- ing simple method of retain- ing umbilical hernia in an in- fant. UMBILICAL HERNIA 217 is roduoiblo, the patient may thus be made comfortable. If the hernia is irreducible, lioAvever, one must resort to a radical operation unless it is Fig. 123. — Adult umbilical hernia (Massachusetts General Hospital). Fig. 124. — Mayo's operation, showing the transverse elliptic incisions and exposure of the neck of the sac (W. J. Mayo). obvious that such an operation will endanger life. Until recent j^ears the radical cure of umbilical hernia was unsatisfactory^, for the method used was that of stitching together the two recti muscles. Muscles are 218 THE ABDOMEN weak barriers. In these cases the recti are worn-out, flabby structures, which permit the hernia to relapse. Aponeuroses are needed for the work. Moreover, the great ring in these cases is almond shaped, with its greatest diameter from side to side. A satisfactory operation con- sists in drawing these aponeuroses together and overlapping them from above downward.' Make transverse crescentic incisions about the Fig. 125. — Three mattress sutures introduced CW. J. Mayo). hernia and expose the base of the sac; then clear thoroughly by gauze dissection the aponeuroses for two or three inches around the neck of the sac. Cut away the fibrous and peritoneal coverings of the hernia, return viscera to the abdomen, and cut away redundant omentum. Enlarge the ring transversely for one or two inches at either lateral end of the hernial ring, and strip back the parietal peritoneum for an inch or Fig. 126. — Mattress sutures tied above, and upper edge of incision stitched to surface of aponeurosis below (W. J. Mayo). two. Our purpose next is to slip the lower aponeurotic edge of the ring beneath the upper edge — between it and the peritoneum. Pass a suffi- cient number of wire or silk mattress sutures from the lower to the upper flap, but before tying them, make upon them tension sufficient to 1 W. J. Mayo, Jour. Amer. Med. Assoc, July 25, 1903; J. C. Warren, Boston Med. and Surg. Jour., October S, 1903. VENTRAL HERNIA 219 bring together the underlying peritoneal edges. Sew up the peritoneum with a running catgut stitch. Then fix the mattress sutures, and tack down the free upper edge to the lower aponeurosis with a buttonhole catgut stitch. Close the skin wound by your usual method. In the case of very fat persons, with pendulous abdomens, I have seen J. C. A^'arren excise, in addition, a great mass of adipose tissue, hke the section of an orange, across and across the abdomen below the navel. This relieves the strain over the fresh umbilical wound, and seems to offer a better chance *of permanent cure. In the after-treatment the ab- domen should be supported in a well-fitting swathe for at least four months.^ VENTRAL HERNIA Ventral hernia is a hernia through the abdominal wall at some point not normally w^eak ; through the linea alba, above or below the navel; through the linese semilunares, etc. Writers distinguish hernia jpara-umhilicalis and hernia epigastrica. The causes of these hernise are a weak- ening of the wall at the point affected — congenital, pathologic, or traumatic. Usually the anatomy of the hernia is similar to that of umbilical hernia, but sometimes the peritoneal sac is partially or entirely lacking. Many of these hernise are of great interest. Epigas- tric hernia is rather common. It pro- trudes through weakened portions of the interlocldng aponeurotic fibers in the median line, and gives rise to trains of obscure gastro-intestinal symptoms, especially colicky pains. Portions of omentum become caught; trifling pain- ful swellings come and go, but the hernia rarely reaches a great size.- Another interesting hernia, unfortun- ately too common, is " hernia in a scar," a weak point due to imperfect closure of the w^ound after an abdom- inal section. This hernia is most com- mon as a sequel of the operation for acute appendicitis, but we see it in all parts of the abdominal wall. The treatment of ventral hernia is often difficult. The simple reducible protrusion, with a complete sac, is easily cared for, but the extensive hernia, irreducible, adherent, with numerous sacculations, 1 See W. J. Mayo, Radical Cure of Umbilical Hernia, Jour. Amer. Med. Assoc, June 1, 1907. 2 H. A. Lothrop, Boston Med. and Surg. Jour., March 4, 1897: D. D. Stewart, Amer. Med., July 29, 1905. . 127.— Bartlett's filligree the cure of ventral hernia. for 220 THE ABDOMEN commits the surgeon to a long, laboiious, painstaking dissection. The aponeurosis must be widely exposed for ease in sewing up ; all adhesions must be freed; prolapsed and adherent omentum must be excised, and the viscera must be returned to the abdomen, leaving a free border of peritoneum on either side of the ring. The ring is often enormous; its edges must be refreshed; the various layers identified and separated, and repair of the ring must be made by carefully placed layers of stitches — silk or catgut — bringing the corresponding structures together from either side. The approximation of the aponeuroses must be made by overlapping, for by overlapping is a firm scar best secured. The patient must wear a well-fitting abdominal binder or belt for at least six months after most of these operations,^ DIAPHRAGMATIC HERNIA Diaphragmatic hernia occurs occasionall}'. It maj' be due to con- genital defects in the diaphragm, through which the abdominal contents escape into the thorax; or to wounds, accidental or inflicted during the course of an operation upon the chest-wall; for be it remembered that the lateral and dorsal portions of the diaphragm arch up along the chest- wall as far as the fifth rib, on expiration, leaving a narrow space only between parietal pleura and diaphragm. The operator may, therefore, easily penetrate the abdomen if he open hastily through the lower part of the chest-wall. Diaphragmatic hernia may or tiiay not be covered with peritoneum in the form of a sac. The symptoms of this form of hernia are difficult and obscure, for they point to both a thoracic and an abdominal lesion. There are dyspnea, palpitation, and pain in the chest. There are gastro-intestinal symptoms, pain, flatulence, and constipation; the pain is usually in the epigastrium. A physical examination may reveal tympany high in the chest and a displaced heart. Sometimes the x-ray will show the lungs crowded up and the heart in an abnormal position. Diaphragmatic hernia may become strangulated, in which case the symptoms are those of an}' other strangulation of the abdominal viscera. The treatment of strangulated diaphragmatic hernia is obviously to open the abdomen, reduce the hernia, and treat the viscera as the con- dition indicates. Hitherto no operation is reported as performed upon non-strangulated diaphragmatic heniia. The permanent closure of the ring in the diaphragm is a difficult matter, for when closed, it is wont to open again and the hernia to return. The best suggestion hitherto made is to sew the stomach with two or three rows of stitches against the diaphragm and over the repaired ring. Gluteal and sciatic hernioe are rare forms of hernia which protrude respectivel)^ through the greater and lesser sciatic notches — natural openings separated by the small sciatic ligament. When one of these hemise becomes large, so as to be distinctly recognizable, it forms a tumor ^ Bartlett's silver wire filligree buried beneath the aponeurosis streng:thens the wound. RETROPEKITONEAL HERNIA 221 eovering in the anal region and extending toward the median Hne. These hernia; rarely become strangulated, but when the symptoms are urgent, the surgeon must cut down upon the mass and follow it up into the sciatic notch in order to reduce and cure it. OBTURATOR HERNIA About 200 cases of obturator hernia have been reported. These hernise are found chiefly in old women, and are often associated with hernise in other regions. They appear as swellings at the upper por- tion of the adductor longus, internal to the femoral vessels. Make the examination with the thigh flexed, adducted, and rotated outward. The diagnosis is not easy. The hernia has never been operated upon hitherto except when strangulated. The results of operation are un- favorable, for it is extremely difficult to make the deep dissection and properly to treat the diseased bowel. I suggest that after loosening the sac and freeing the neck it would be well to open the abdominal cavity from above and handle the viscera from this point of vantage. RETROPERITONEAL HERNIA There are various forms of retroperitoneal hernia — hernia which burrows behind normal inoffensive looking peritoneal bands and folds. Fig. 128. — Site of retroperitoneal hernia. J. B. Blake has described four such hernise about the head of the cecum, and Moynihan has written an elaborate work on the subject, in which he deals especially with duodenal hernia — hernia through the foramen of Winslow and behind the duodenum. Hernia escapes also through 222 THE ABDOMEN abnormal openings in the mesentery and the broad ligaments. Both Mo^^lihan and A^^ J. Mayo describe a jejunal hernia in the neighborhood of a gastro-enterostomy operation field. Obviously, all these forms of internal hernia are impossible of exact diagnosis. The symptoms arc those of intestinal strangulation, for which the surgeon must operate; he must treat, on general principles, the viscera as well as the hernial opening, and according to the conditions which he discovers. Glancing back over the general subject of abdominal hernia, one observes that certain forms are common, and that other forms are ex- tremely rare; that the whole subject is a subcHvision of intestinal surgery; that strangulation is the possible serious outcome in all cases, and that a proper broad rule is to relieve and repair all hernia? wherever found. CHAPTER VIII PERITONEUM AND RETROPERITONEAL SPACE The subject of the peritoneum is one of the most difficult and intricate in surgery. The anatomy of the peritoneum is puzzhng, its diseases are often obscure, and their treatment has been a matter of hot debate. When you find the treatment of a- disease debated and opposing views taken almost with acrimony by competent men, you may assume fairly that the end is not yet. The best one can do is to adopt that course which appears to be supported by the greatest weight of rational opin- ion, provided it agrees with one's own sense of the rational and one's own experience. Generally, in the case of constantly debated subjects, you will find in the course of time that the best men are drifting toward definite and similar conclusions, however far apart they may have wandered. The peritoneum is a serous membrane forming a cavity, and this cavity has been likened to a great lymph-sac. Its surface is extensive, probably somewhat greater than that of the skin of the whole body. It is a closed cavity in man; in woman it communicates through the Fal- lopian tubes with the outer world. It has a great capacity for absorp- tion, especially in the diaphragmatic region, where the stomata in the central portion of the diaphragm drink up fluid with great rapidity. When irritated, the peritoneum throws out rapidly a copious exudate, which may be fibrinous and cause adhesions of the serous surfaces; or the exudate may be a fluid, rich in albumin, and easily changed in char- acter, or it may be seropurulent. Owing to these peculiarities, the peritoneum may become rapidly involved in dangerous infections; at the same time, it has remarkable powers of recuperation. Its nicely ad- justed mechanism resents irritation, but it can dispose of an immense volume of poison. Our greatest interest in the peritoneum centers, therefore, in 'peritonitis, of which there are various forms — acute, chronic, tuberculous, and malignant being the most important. Moreover, there are diseases of the retroperitoneal space— infections with their resulting inflammations and abscesses, diseases of the lymph-nodes, and tumors. Injuries of the peritoneum make up another subject of broacl general interest, which we have discussed already when we were dealing with injuries and special diseases of the abdomen. ACUTE PERITONITIS Acute peritonitis is divided anatomically into localized and diffuse peritonitis. I have treated of the former in describing certain forms 223 224 THE ABDOMEN of appendicitis. Similar forms of localized ])oritonitis may develop about an}' diseased organ, as the Fallopian tubes, gall-bladder, duodenum, stomach, etc. This limited peritonitis results in an exudate of fibrinous character, which mats together neighboring organs, and locks up in separate pockets the secretions as they are ])roduced. Colon bacilli, streptococci, and staphylococci are the organisms commonly concerned in these restricted inflammations, though pneumococci and other rare organisms sometimes arc found. The symptoms are variable and depend on the extent and duration of the disease, as well as upon its point of origin. There are localized pain and tenderness, a fluctuating temperature, rareh' high ; sometimes nausea, and rarel}- vomiting, though there is usually distaste for food. Thei'e may be occasional chills; constipation is common, but absolute obstruction is rare. The diagnosis of any localized peritonitis is based upon finding within the abdomen a mass, usually tender, varying in size and con- sistence, of recent origin, and associated with chills, fever, a quickened pulse, general abdominal discomfort, with malaise, dyspepsia, and con- stipation. This mass represents often an accumulation of fluid, which may remain pocketed for a long time ; it may become absorbed or it may spread — sometimes into the general peritoneal cavity; sometimes into neighboring hollow organs; sometimes by burrowing through the skin. When such a mass or focus is discovered, it should be opened and drained. When its presence is suspected but the mass is not definitely located, one should explore for it. One of the serious results of localized peritonitis is the formation of chronic adhesions, which may persist and cause great subsec[uent functional trouble. I shall refer to the treatment of these adhesions when we come to the subject of chronic peritonitis. Subphrenic peritonitis and abscess is a special and interesting form of localized peritonitis. It may be due to extension from disease of the pleura, of the liver, or of the gall-bladder, and may be confined closely to the vicinity of the diaphragm, and be within the greater peritoneal sac, A more important and interesting form of subphrenic peritonitis is that which appears within the lesser peritoneal sac, behind and below the stomach and the anterior layers of the great omentum. The source of infection may be a perforation of the posterior portion of the stomach, the duodenum, or colon or an acute inflammation of the pancreas. There results a distention of the lesser sac, with the appearance of a tumor above the umbilicus. The colon always lies below this tumor, and never in front of it, as is the case in enlargement of the kidney. Osier mentions a remarkable form of subphrenic abscess containing air, called by Leyden pyopneumothorax subphrenicus. The symptoms in all these cases are those of acute localized intra-abdominal inflammation. When in the neighborhood of the diaphragm, the abscess may be reached either from the front or back and may be walled off and drained successfully. Abscess of the lesser sac is best reached through the gastro- colic omentum; but hitherto operation in this disease has been followed by a considerable mortality. ACUTE PERITONITIS 225 DIFFUSE Peritonitis Diffuse peritonitis (general peritonitis, so called) is the great topic with which we have to deal in this chapter. The pathologic appeai-ances of diffuse peritonitis vary in different patients, and in the same patient even, so that one portion of the abdominal cavity may differ in appear- ance from another. The progress of the disease is influenced both by gravity and by the lymphatic arrangements — for instance, the peri- tonitis which results from a perforating duodenal ulcer advances rapidly down the right flank, as the septic material descends by the side of the spinal column, over the right kidney, and ascending colon, toward the pelvis. Peritonitis starting from the appendix spreads at first into the pelvis, then extends around on to the left side, involving gradually the sigmoid, left renal, and splenic regions. At the same time it extends more slowly toward the liver, so that active organisms will be found in varying numbers in these places, while in the center of the abdomen there may be no organisms whatever, but nearly always an abundant exudate, rich in toxins. Von Mikulicz wrote a paper, often quoted, and des- cribed three forms of diffuse peritonitis — diffuse septic, gangrenopurulent, and fibrinopurulent. You cannot alw^ays distinguish these with cer- tainty, save postmortem. In practice, the appearance of the exu- date and of the peritoneum, the extent and rapiditj^ of effusion, and the constitutional reaction of the patient determine for j^ou the gravity of the condition. Writers still talk about idiopathic peritonitis — an archaic term, which should find no place in our vocabulary. Sometimes we fail to isolate organisms from the abdomen in certain cases of diffuse perito- nitis; but we may be certain that organisms somewhere are present, even though we fail to find them. A chemical or traumatic, non-infecting form of peritonitis frequently occurs, but is always strictly limited, and is properly a reaction of the peritoneum — a process of repair following some injury, such as the inser- tion of a drainage-tube or wdck, rough handling, the twisting of an ovarian tumor. These simple forms of peritonitis generally result harm- lessly if prompt^ relieved, except in so far as they may give rise to adhesions destined to make trouble. Diffuse infectious peritonitis agitates us especially. The sources of infection have been detailed already. The most virulent organisms come from the intestinal tract, and Harvey Gushing long ago showed that the upper portions of the canal have relatively few bacteria; that the ileum has the greatest number, while there is a sudden drop after passing the ileocecal valve. Besides the intestinal canal, from which bacteria may escape, there is the possibility of infection spreading from disease of the ischiorectal fossa and of the genito-urinary apparatus^ and from penetrating wounds. The following table is interesting: * 1 Von Bergmann's System of Surgery, vol. iv, p. 165. 15 226 THE ABDOMEN SOURCES OF PERITONITIS IN 446 CASES Appendicitis 115 Stoniuch Jiml cluodi-nuin 68 The rest of the intestines 118 Female genitals 81 Gall-bladder 10 Kidney and urinary bladder 10 Pancreas 2 Spleen 1 I'nknown 35 Post-operative 4 Hematogenous origin (nephritis, etc.) 2 These infections are most commonly due to colon bacilli, then to streptococci, staphylococci, and, more rarely, gonococci, pneumococci, gas-forming bacilli, and a few other rare organisms. The infection is usually mixed. According to the predominance of one or other of these organisms the progress of the disease is slow or rapid, and the morpho- logic appearances differ. The colon bacillus sometimes produces but slight irritation, even with a considerable seropurulent exudate, but oc- casionally it may produce an extensive irritating effect, causing a rapid distention of the cells of the peritoneum and occasionally gangrene even. Staphylococci cause a rapid fibrinous exudation with an abundant deposit; for this reason the cjuantity of pus in the cavity is usuall}- small, but w^hen it is large, it is of the seropurulent type. Streptococci give rise to little if any free pus, and the peritoneum has a peculiar dry, granulated, blistered appearance. As a rule, however, with mixed in- fections in which the colon bacillus predominates there is an abundant secretion of fluid, the peritoneal cavity containing many ounces of a rather thin, turbid material, with occasional patches of agglutination and excoriation, but with a variety of appearances in different portions of the abdomen. Symptoms. — The symptoms of diffuse peritonitis are as various as are the pathologic appearances. One must consider, first, the initial disturbance — appendicitis, or whatever it may be — such disturbances as I have already described in detail. The localized symptoms due to these special lesions extend gradually as the inflammation extends until the symptoms and signs become wide-spread as large areas of the peri- toneum are involved. In general terms there are superadded to the intense initial abdominal pain chilly feelings or an actual rigor. The pain extends over the abdomen and is aggravated by pressure and by moving. The patient lies on his back and tries to relieve the tension by drawing up his knees and having his shoulders raised. He breathes in a shallow, rapid fashion of the costal type, because contraction of the diaphragm increases his pain. He holds his abdominal muscles rigidly contracted in order to keep at rest the inflamed pei'itoneum. Clradually, the abdomen becomes distended, tense, and tj'mpanitic; the pulse rapid, small, hard, and wiry, ranging from 110 upward. The temperature may rise to 103°, 104°, and 105° F. after a chill, but its average elevation is moderate. With collapse or later in the disease it becomes subnormal. The tongue, at first white and moist, becomes dry, red, and cracked. ACUTE PEKITOXITIS 227 Nausea and vomiting appear early, and vomiting causes great pain. The patient ejects first the <;a.stri(' eontents, then a yellowish and bile-stained fluid, then a greenish lluid, and often, late in the disease, a brownish- black liquid, broken-down blood with a fecal odor — the contents of the small intestine. There may be an initial diarrhea, but constipation rapidly ensues. Sometimes there is frequent micturition; less often, retention. The urine is scanty, high colored, and with a large quantity of indican. The facial expression is the Hippocratic facies I have described before — "a sharp nose, hollow eyes, collapsed temples; the ears cold, contracted, and their lobes turned out; the skin about the forehead being rough, distended, and parched; the color of the face being brown, black, livid, or lead colored" (Sir James Paget). When you come to the physical examination, you will find two dis- tinct types of abdomen — the distended and the retracted. The dis- tended abdomen is the more conmion. It may be enormously swollen, drum-like, very tense, glistening, slightly reddened; everywhere tym- panitic, even over the hepatic and splenic areas; too exquisitely tender for satisfactor}^ palpation; often the recti muscles show spasm on being irritated. Fluid may be made out in the flanks — fluid which shifts as the patient turns. Rarely the abdomen may be flat and board-like if there be no exudation and but slight intestinal distention in the case of a rapidly progressive infection. Most cases of diffuse peritonitis proceed to a termination in death. The severe forms may kill within forty-eight hours, but more commonly the disease lasts four or five days. When the patient dies early, he dies from a rapid, overwhelming toxemia. If he lingers, he dies from a slow toxemia, in profound depression, in a low muttering delirium, with lijjs blue, extremities cold and clammy, the pulse irregular, the heart- sounds weak, the breathing shallow. The leukocytosis is never a significant feature of these cases. It may be high or low, but often the patient dies with a white count which has never run above 15,000. The diagnosis of diffuse peritonitis is usually obvious, and is founded upon the initial severe pain, the tenderness gradually extending, the abdominal distention, effusion, fever, collapse, vomiting, and constipa- tion. One must differentiate it from sundry other diseases — acute enterocolitis, in which the pain is more colicky and a diarrhea frequent; hysteric peritonitis, which Osier describes as deceiving the very elect. It must be very rarely, however, that this cannot be distinguished from an infectious peritonitis; intestinal obstruction, in which the prostration comes on more slowly, and the pain, fever, and tenderness are less marked. However, intestinal obstruction is a frequent cause of peri- tonitis; rupture of an abdominal aneurysm or embolism of the superior mesenteric artery; acute hemorrhagic pancreatitis; and rupture of a tubal pregnancy. All those conditions may simulate peritonitis, and all may be associated with it, but whatever the true condition, the symptoms are those of an alarming intra-abdominal disease demanding immediate 228 THE ABDOMEN treatment by operation if the patient's life is to be saved and if liis con- dition permits. In the treatment of -J '0mst' Alonzo Clark and Ochsner are correct, of course, when they pro- claim that the intestines must be put at rest ; but others are correct when they assert that we must oHminatc the primary focus of disease. More- over, we must in some fashion ])rovide for the escape of septic material from the abdomen; we must encourage the secretory organs — the kidneys, most of all — to take up their allotted task ; we must nourish the organism; we must quench thirst; we must stimulate the flagging circulation; we must sub- due pain. Every one of these details is im- portant. We have learned from the researches of Cannon and F. T. Murphy that certain im- pressions will check intestinal peristalsis, while others may be applied without that effect on the bowel. Those investigators put to them- selves the question, why is it that a temporary intestinal paralysis follows almost every ab- dominal section? In their experiments on ani- mals they opened the abdomen, exposed the viscera to the air for a time, and then sewed up the abdomen. Xo intestinal paralysis resulted. -^^^^JBr^^-ffA^j ■ '-" ft.r'hO- Huui-t-.i of. A I'lj:. ]■_".». — Flushing the abdominal cavity. In like manner, after filling the abdomen with salt solution, no paralysis followed; but handling the bowel caused a paralysis of peristalsis, and the more and the rougher the handling, the longer the paralysis — for four, six, twelve, and even twenty-four hours. Now, abundant flushing of the abdominal cavity in case of diffuse ACUTE PERITONITIS 231 peritonitis was an early and obvious expedient in treatment after remov- ing the source of infection — flushing through a tube passed deeply into all parts of the cavity, using warm decinormal salt solution, several gallons, and leaving a goodly amount in the cavity. This method is employed by many surgeons. One must endeavor not to disturb and bruise the intestines, and should work through a single opening below the navel, when possible. Do not wipe the intestines; by so doing one adds to the traumatism and increases the paralysis. For like reason do not eviscer- ate. Do not sew up the abdomen: drain it. Fowler's position assists drainage; of that I shall speak later. Do not feed by the mouth until convalescence is established. As for enterostomy — direct drainage of the distended gut through a tube low in the ileum or in the cecum — that is a maneuver of questionable expediency. In an admirable essay Greenough ^ has discussed this subject, and concludes that the opera- tion has a place in cases of extremely grave peritonitis. In this con- nection he formulates 17 interesting conclusions. Of these, note the following : " The obstruction of the intestine in diffuse peritonitis is the result of a combination of causes. " The most important cause is suspension or paratysis of peris- talsis. " Paralysis of peristalsis is due to inhibition, to toxic paralysis, and to the paralysis of distention. '' Mechanical causes, such as infiltration of the bowel-wall and light adhesions, in certain cases contribute to this paralysis. " Enterostomy is indicated, in addition to other operative measures, in graver forms of diffuse peritonitis. " Its greatest advantage is the drainage of the gases and decompos- ing contents of the bowel, and the relief of paralysis of peristalsis." I have thus presented the main features of the argument of those who advocate enterostomy, because the importance of the subject warrants it, and because the matter is still sub judice, but the figures adduced and my own experience do not impress me with the value of this procedure. After a careful studj- of many papers, much discussion wdth winters, an elaborate comparison of statistics, and a general hospital experience of twenty-two years, I have come to definite conclusions regarding the treatment of diffuse peritonitis. In general terms — every patient with diffuse peritonitis should be operated upon as soon as seen unless, in the judgment of an experienced surgeon, he is nearl}- moribund. The operation should be reduced to a minimum in time and extent. The viscera should not be handled except so far as is unavoidable in remov- ing the primary focus of disease. Irrigation should be practised when the abdominal fluid is thick or contains numerous masses of fibrin and detritus. These should be washed out thoroughly with several gallons of warm decinormal salt solution. In the absence of these masses and when the fluid is thin, irrigation is needless. Adequate drainage should 1 R. B. Greenough, Boston Med. and Surg. Jour., May 19, 1904. 232 THE ABDOMEN be provided,' the intestines should l)c kcjjt at rest after the operation, and the organism should be sustained. To accomplish these objects I have followed for the past six years the methods formulated In- J. Jl Murphy.- For these methods my res- pect is constantly increasing, and 1, therefore, advise the following pro- cedures. Open the abdomen as low as possible, through a short incision, three or four inches long. Seek and remove the primarv disease. By the short incision shock is minimized, as the intestines are but little exposed. They should not be allowed to escape; from the abdomen. Do not irrigate the abdomen except under such circumstances as I have described on p. 231. Under no circumstances attempt to wipe clean the peritoneum, inasmuch as the adherent coagulated lymph acts Fig. 130. — The iron bed in position on the .springs of a ward bed. Draw-sheet ar- ranged as for continuous irrigation (W. D. Gatcli). as a protective and its removal gives an opportunity for the absorption of fresh toxins. Drain through the operation wound, and drain the pelvis through a stab-wound above the pubes. Van Buren Knott, in a valuable paper,^ advises draining the pouch of Douglas in women through the vagina — an admirable measure. Employ Fowler's postural method to assist drainage. This method, described by George Ryerson Fowler,* of Brooklyn, in 1900, is an advance of great importance.^ We have seen that the peritoneum in the region of the diaphragm is most rich in its lymphatic connections, while the pelvic peritoneum is relatively poor 1 See Robert C. Coffey, Tlie Principles and Mechanics of Abdominal Drainage, Jour. Amer. Med. A.ssoc.,' March 16, 1907. 2 J. B. Murphy in the Practical Medicine Series, Surgery, series of 1903. 3 Van Buren Knott, Ann. Surg., .Julv, 1905. *G. R. Fowler, Medical Record, January 16 and April 14, 1900. 5 Russell S. Fowler, New York State Jour. Med., October, 1907. ACUTE PERITONITIS 233 in such lymphatics. For this reason peritonitis in the upper portion of the abdomen is more fierce in its coiu'se and more immediately over- whelming than is pelvic peritonitis. Our endeavor must, therefore, be to drain septic products away from the upper to the lower portions of the abdomen, and we know that the trend of peritonitis is largely dependent on gravity. We, therefore, employ Fowler's position, which consists in sitting the patient in a posture as nearly upright as he can maintain without distress or fatigue. Then the fluids gravitate to the pelvis and are drained away by tubes and wicks placed there to receive them. The pumping action of the diaphragm also forces the fluids down. As LeConte ^ remarks: '' It must be remembered that it is not the quan- tity of fluid present which is harmful, but rather the extent of the peri- Fig. 131. — Special drainage-tubes (Crandon and Scannell). toneal surface which comes in contact with it, so that a quart of pus contained in a round cavity would be less dangerous than an ounce thinly coating over the peritoneal surface." I use large rubber drainage-tubes of the split pattern suggested to me by B. G. A. Moynihan — one tube through the operation wound to the initial focus of disease, one through the suprapubic opening to the bottom of the pelvis, and one in the vagina, if that is incised. The wounds are covered with an abundant absorbent dressing, which must be changed frequently, as it quickly becomes soaked. The whole operation should take a short time in most cases, and the amount of anesthetic used should be small. 1 R. G. LeConte, Ann. Surg., Februarj-, 1906. '234 THE ABDOMEN I do not approve of multiple punctures of the bowel; as for a single puncture, that accomplishes nothing; nor do I approve of injecting saline cathartics into the bowel. The after-care of the patient is an extremely important part of the treatment. Our purpose is to leave the l)owels absolutely at rest until nature has had a chance to reassert herself. So we give nothing by the mouth, but we introduce abundance of water into the rectum by the well-known " seeping" method employed by Murphy.* For this pur- pose insert within the sj^hincter a large-sized nozzle with several open- ings, fed through a long tube from a reservoir elevated but a few inches above the level of the anus. A gentle trickle of salt solution is thus led into the rectum, and led so slowly that it is absorbed as fast as it flows in. Many quarts are thus taken up in the course of twenty-four hours, the stream being intermitted from time to time if it seems best. Thus two important objects are attained: first, the septic stream from the peritoneum into the lymph-channels is reversed; fluid pours into the peritoneum instead of away from it ; the patient's upright position causes this fluid to gravitate to the pelvis, and an abundant discharge escapes and soaks the dressings. In the second place, the increased amount of water in the circulation stimulates the heart and kidneys; it allays thirst, and supplies nutriment. Moreover, if necessaiy, liquid absorbable food may be mixed with the solution injected. The output of urine increases surprisingly, man}' pints being passed in twenty-four hours. It is interesting to observe in this connection that fluid thus indirectly introduced into the peritoneal cavity maintains continuous^, effectively, and without irritation the action which we crudely attempted to pro- duce when we pumped a great quantity of water into the belly at the time of the operation. Seeping supplants sluicing. Whereas we expected a death-rate of from 70 to SO per cent, from acute diffuse peritonitis under previous forms of treatment, it seems reasonable to expect, judging from the relatively few cases as yet avail- able for statistics, that the mortality ma}- be kept below 30 per cent, if we follow the treatment I have just described. CHRONIC PERITONITIS Chronic peritonitis is an unsatisfactory term, for it is often hard to determine where acute peritonitis ends and chronic peritonitis begins. We recognize two forms: exudative chronic peritonitis and adhesive chronic peritonitis; while it would be proper enough to include tubercu- lous and malignant peritonitis under the caption chronic. Exudative peritonitis is so closely allied clinically to tuberculous peritonitis that it is extremely difficult to distinguish the two. The con- dition is rather rare, and is characterized by a general and abundant fluid exudate. We do not know what causes exudative pei-itonitis, though it has been ascribed to catching cold and to traumatism. The fact that it is most common in young women and that it frequently starts 1 J. B. Murphy, Proctoclysis in the Treatment of Peritonitis, Jour. Amer. Med. Assoc, April 17, 1909. CHRONIC PERITONITIS 235 in the pelvis suggests that its origin lies in the Fallopian tubes. Indeed, it has been observed to occur for the first time at the beginning of men- strual life. It comes on gradually with fluid slowly collecting in the abdomen, with or without pain. If the fluid accumulates in great amounts, it may interfere with the functions of the abdominal organs, especially the intestines. Sometimes small nodular masses like pebbles may be felt in the umbilical region. There is fever often. The general health is affected, and the patient becomes pale, weak, and emaciated. Not infrequently there is an associated pleurisy. It is almost impossible, by an ordinary examination, to distinguish such a case from tuberculous peritonitis, but a proper conclusion may be reached through the tuberculin test, or by inoculating animals with the aspirated fluid. One must distinguish the disease from the various forms of ascites also. A majority of the patients recover under the use of internal remedies, mercurial inunctions, and hydrotherapy. Treatment by operation is indicated in obstinate cases, especially if one cannot exclude tuberculosis. Sometimes the exudate will disappear after repeated tappings. Sometimes an abdominal section, with remo- val of the fluid and irrigation, cures promptly. Chronic adhesive sclerosing peritonitis or plastic peritoneal sclerosis is an interesting disease, and not an uncommon one. Writers are wont to complain that text-books give scant attention to diseases in which they themselves happen to be especially interested, and I find Wetherill ^ remarking of sclerosing peritonitis that it " is treated but slightty and irregularly in American text-books." This disease occurs at one or at several points in the peritoneal cavity, but favors especialty the region of the Fallopian tubes, the gall-bladder, the flexures of the colon, the posterior part of the peritoneum, the root of the mesentery, the mesosigmoid, and the omentum. There result a thickening and a shrinking of the peritoneum. The disease may also be a sequel of acute infection of the intestine and of traumatism. Moreover, it may start in a chronic form, and without an acute stage may develop far without the patient being aware of any cause for its onset. Histologically, one observes extensive subperitoneal scleroses. There is no exudate. The symptoms are obstinate constipation, leading to obstruction even, with nausea and vomiting, pain, and tenderness. In the milder cases there are constant abdominal uneasiness, dyspepsia, malnutrition, and occasional attacks of colicky pain several hours after eating, since the dense adhesions interfere with the normal flow of the intestinal stream. The surgical treatment of this disease is not always satisfactory, though it is the only treatment which gives any prospect of permanent rehef. The operation consists in opening the abdomen and dividing the bands of adhesions which are found. It may be necessary also to remove organs which appear to be the source of disease — such organs as the appendix, the gall-bladder, and the Fallopian tubes. Sometimes the patient is cured permanently by the operation; sometimes the dis- 1 Jour. Amer. Med. Assoc, March 5, 1904. 236 THE ABDOMEN ease recurs and may extend slowly until it involves the greater part of the peritoneum. Various methods have been devised to prevent the reformation of adhesions, such as the introduction of Cargile membrane between wounded surfaces, the copious dusting with aristol, and the in- terposition of omental grafts. These substances are often useful, and since one can never foresee the outcome of the operation, their employ- ment is justifiable. On the whole, we may not regard the outlook as favorable, though I cannot agree with Beck ' in his statement that " my experience in cases of chronic, progressive, adhesion-forming peritonitis, as it is observed idiopathically, as well as after appendicitis, is absolutely bad. The nature of this peculiar condition, characterized by a multitude of cob- web-shaped bands, is not yet sufficiently elucidated." Tuberculous peritonitis is one of the puzzles of surgical practice. It is insidious; it is confusing; it ma}^ simulate a great number of diseases. Whenever you see a patient with somewhat distended abdomen, with indefinite dj^speptic symptoms, and with an uncertain history of ab- dominal pain, you must think of tuberculous peritonitis. Appendicitis and tuberculous peritonitis are so common and so elusive often that they should alw^ays be in the mind of the surgeon when he examines an ab- domen, though one may choose to relegate appendicitis to the group of acute diseases, and tuberculous peritonitis to the group of chronic diseases. One finds three distinct forms of tuberculous peritonitis, which have been classified as — (1) The ascitic form; (2) the fibro-adherent ; (3) the ulcerative. Hawkins, in a much-quoted article, describes four clinical varieties: the latent; the severe, with ascites and a spontaneous tendency to remissions or incapsulation; a cheesy, purulent form; a fibrous- adhesive form. Such classifications are all veiy well, but, unfortunately for the clinician, these forms are not always clearly marked, w'hile more than one may be present in the same individual. Tuberculosis of the peritoneum rarely is primary — a considerable majority of the cases are secondary to tuberculosis of the lungs, or the primary focus may be in the Fallopian tubes, the intestines, the appen- dix, and the abdominal lymph-nodes; the infection maybe brought by the blood-stream to the peritoneum from a tuberculous center in some remote part of the body. We need not consider here the rather uncom- mon, acute, miliary tuberculosis, which is but part of a general tubercu- losis.^ We are dealing now- with a chronic process. Tubercles may be found scattered or thickly set over the peritoneum, associated with an exudate free in the peritoneal cavity, or one sees nod- ular masses undergoing caseous or ulcerative change.s— the nuclei of further trouble. There may be extensive matting of viscera, with in- filtration of the organs, producing a friable condition of tissue. There may be extensive involvement, ulceration, and destruction of organs. The omentum and the intestines are the parts most frequently affected. 1 Carl Beck, Amer. Med., April 1, 1905. 2 Brunn, Cent. f. allg. Path. u. path. Anat., 1902. CHRONIC PERITONITIS 237 The symptoms of tuberculous pciitoiiitis are extremely variable, but, as a rule, one finds pain coming and going, fever, emaciation, anemia, anorexia. The bell}- i.s ballooned; there is often ascites, with diarrhea alternating with constipation. Sometimes there appears an inflamed zone about the navel; rarely there are sinuses dischaiging pus or feces. Palpation is unsatisfactory; at different times different impressions are conveyed to the hand; lumps appear and disappear; fluid may be found free, or it may be locked up in pockets. One discovers a condition of tension or hardness in the abdominal wall — a peculiar elastic resistance. Thomayer's sign is often valuable : in the shortening of the mesentery resulting from infiltration the entire mass of intestinal coils may be drawn upward and backward to the right, while fluid will be found ac- cumulated below and to the left. Sometimes the fluid of tuberculous peritonitis accumulates in great amounts. The fig-ures of the Massachu- setts General Hospital, gathered by Shattuck and W. H. Smith, show that the disease is most common between the ages of twenty and thirty, while liability to it cHminishes as we approach the extremes of birth and old age. It is rare in infancy; rarer still after sixty. In making the diagnosis one considers the common symptoms : ab- dominal pain; the frequent diarrhea; the nausea and vomiting,\]ie fluid in the abdomen, the masses to be felt. Leukocytosis is infrequent; the temperature is usually slightly elevated, especially in the e^-ening. The tuberculin test is generally positive, but a much more satisfactory test is the injection of the abdominal fluid into guinea-pigs. Twenty-five years ago we were taught that tuberculous peritonitis is an invariably fatal disease. To-day we have abundant proof that it is not invariably fatal, and that patients often recover, under all varieties of treatment and under varying conditions of hygiene. A number of statistics show we are safe in concluding that, under proper care, 30 to 40 per cent, of the patients will recover. In chscussing the treatment of tuberculous peritonitis writers have been wont to quote the case of Spencer Wells, who operated upon a young woman for an ovarian cyst some forty years ago, and found a tuberculous peritonitis. He sewed up the belly and the patient got well. So, men have pointed to this case as a post hoc, propter hoc. In large measure, therefore, the discussion of the treatment of tuberculous peri- tonitis has centered around the question, to operate or not to operate. Tntil recently the discussion was largely futile, because onh^ recently have we come to see clearly that operation is of benefit to those patients mostly from whom the focus of disease can be removed. Numerous cases are reported in which the abdomen was opened, or was opened and drained, or was irrigated or variously treated. In any case the operation was extremely simple, and many of the patients got well; so clinicians have been debating in what way the operation benefits. There have been numerous attempts at an explanation — most of them more or less meaningless. Eichberg ^ sums up the debate as to why lap- arotomy cures tuberculous peritonitis by saying " because it does not." ^ Joseph E. Eichberg, Jour. Amer. Med. Assoc, October 3, 1903. 238 THE ABDOMEN Such a statcinont is too sweeping. It is logical to doubt the beneficial effect of laparotomy when the abdomen has been opened, washed out, and sewed up without the removal of a focus, but with the subsequent recovery of the patient. In such a case one may reasonably claim that the patient would have recovered under medical treatment. On the other hand, I agree with J. B. Murphy when he says: " The benefit from an operation for tuberculous peritonitis will depend upon— (a) The removal of the source of continued supph^, which can almost uniformly (?) be accomplished; (b) the degree of adhesions in the peritoneum; (c) the reparative stimulation produced in the peritoneum by the opera- tion." ' Since the Fallopian tubes are a common source of infection, it is ob- vious that removal of the tubes, in the case of young women suffering from tuberculous peritonitis, will effect a cure. On the other hand, men are not such proper subjects for operation, and are wont more than women to recover under medical treatment. Further, those cases with few adhesions and abundant fluid in the cavity will often recover rapidly after the operation of opening and flushing.- Those cases in which the cavity is obliterated by adhesions are not improved by any operation. Finally, since we know that many cases of tuberculous peritonitis are due to extension from disease of the chest, and since we are assured that pulmonary tuberculosis does not contravene the pos- sibility of a cure of peritoneal tuberculosis, we are justified in asserting that a large number of cases of peritoneal tuberculosis secondary to pulmonary tuberculosis will recover without operation. If no opera- tion is done, do not keep the patient in the hospital. Insist upon a con- tinuous out-of-door life, with an abundance of nutritious food and, if possible, eliminate mental strain and anxiety. Malignant peritonitis — the involvement of the peritoneum in cancer or sarcoma — need not detain us further than to note that primary malignant disease of the peritoneum is rare, but that in advanced malig- nant disease of the ovary, intestines, and other abdominal organs, the peritoneum ma}' become extensively involved in metastatic growths. The omentum especially may be found to be the seat of secondary growths. In such cases the abdomen usually contains an abundant, thin hemorrhagic fluid, which may be withdra-uTi by aspiration if it is so great as seriously to interfere with the functions of organs. Any further operation is useless, as the condition is fatal and operation always hastens death. Palliative measures alone are of service. THE RETROPERITONEAL SPACE The retroperitoneal space is not a space. It is all that indefinite, ill-defined area which lies immediately outside of the peritoneum. Now, it is the well-defined plane beneath the abdominal and back muscles; 1 J. B. Murphy, Practical Medicine Series, General Surgerj-. series 1905, p. 288. 2 The student should consult A. Dijll's paper in rcfjard to vioform irrigations, Arch. Internal, de Chir., 1907, No. 5: quoted also in the Practical Medicine Series, vol. ii, General Surgery, for 1908, p. 327. THE RETROPERITONEAL SPACE 239 again, it is that hypothetic area which lies in and follows the folds of the broad ligaments, omentum, mesentery, and other such structures. It is made up everywhere of more or less loose connective tissue, rich in lymph-channels, and with an abundant blood-supply. Its intimate relations with the peritoneum and abdominal cavity make it interest- ing, and magnify an importance which would be otherwise slight. Serious inflammations occur in the retroperitoneal space — inflamma- Fig. 132. — Retroperitoneal lymph-nodes (redrawn from Sobotta). tions which may involve the neighboring peritoneum. Sometimes tumors arise there, and in the course of their development incommode abdominal organs and simulate tumors of the abdominal viscera. Tuberculosis of the retroperitoneal lymph-nodes and the in- volvement of those nodes in Hodgkin's disease, cancer, and like affections form an interesting chapter, becoming more apparent with our increas- ing knowledge. 240 THE ABDOMEN The nodes of the retroperitoneal .space foini two princi})ai and equally important groups — the mesenteric group and the lumbar group. The mesenteric gi'oup of nodes lies in the mesentery of the intestines and is closely associated with the mesenteric vessels. These nodes form the filter for the intestinal lymphatics. The lumbar group of nodes lies close to the lateral and anterior portions of the vertebral column, from the origin of the superior mesenteric arteiy down to and below the bifur- cation of the aorta; the}' have some slight connection with the alimen- tary tract through the lymphatics of the stomach and i-ectum, but their important connection is with the lymph-channels from the legs, the pelvis, and the l-ower parts of the trunk. The}' are connected with the thoracic nodes also. Both sets of nodes are often invoh'ed in disease, especially in tuber- culosis. There is the general miliary tuberculosis, which need not concern us as surgeons, as well as chronic tuberculosis, with a general involvement throughout the body. More rarely, the retroperitoneal nodes alone may he tuberculous, and this is especially true in the case of children.^ There are three important sources of infection : direct extension from adjacent tissues; infection through the blood-stream, and infection through the lymphatics. In children, the mesenteric group infected from the intestines [typhoid, etc.], is most commonly involved; in adults, the lumbar group. The course of the disease is slow, but while present, a tuberculous peritoneal node is always a serious menace to health and life. Nodes become enlarged and break down, forming masses of tuber- culous detritus or calcification. They may become encysted and ^^•alled off and cease to cause trouble. More frequently, however, the disease of the lymph-nodes spreads, involving node after node, until the abdom- inal cavity seems to be filled with masses crowding the viscera, and associated with numerous adhesions. The disease may invade the peri- toneal cavity and give rise to tuberculous peritonitis. The symptoms are usually gradual, for a long time earh- in the disease there are occasional dull pains associated with deep localized tenderness. Later the abdomen may become distended and ascites or jaundice even may develop. At the same time there are cachexia, intestinal disturb- ance and chronic intestinal obstruction, with large, irregular, easily palpable masses within the abdomen. This is the condition which was formerly called tabes mesenterica. The patient dies fi'om inanition and toxemia. The diagnosis is by no means easy always. One must distinguish the disease from malignant neoplasms, vertebral tuberculosis, abdominal aneurysm, osteomyelitis, osteo-arthritis, infectious arthritis, and, as Painter and Ewing point out. from spinal rigidity due to inti'a-abdominal inflammatory disease. A common error is to mistake inflammation of the retroperitoneal lymph-nodes for appendicitis. One should never mistake inflammation of these nodes for acute appendicitis, but the 1 P. F. Morf, New York Med. Jour., vol. Ixxviii, p. 410: C. F. Painter and W. G. Ewing, Amer. Med., September 24, 1904: T. M. Rotch, Pediatrics, pp. 392, 843, etc. THE RETROPERITONEAL SPACE 241 adenitis does closely resemble chronic appendicitis, and I have several times seen the abdomen ojx-ned under this misapprehension. The ircatvicnt is sometimes operative, but more often general hygienic measures suffice — the course familiar to us in the treatment of all forms of tuberculosis: an open-air life, with careful dieting and absolute rest. Sometimes, in addition to this, one may greatly help the patient by applying mechanical supports, such as the leather or plaster jacket which holds the body rigid, promotes comfort, and favors absorption. Opei'ations are seldom useful, and one does them ordinal ily only to relieve special symptoms, such as obstruction or other forms of general peritoneal involvement. Especially it may be necessary to remove large masses developing in and destroying the omentum or causing extensive omental adhesions. In these cases one must always drain the field of operation. The lumbar glands are the more frequent subjects of opera- tion. On account of their nearness to the spinal column, their disease may simulate spinal disease — indeed, they may extend to and involve the spinal column. In any case they may give rise to extensive cold abscess, pointing in the lumbar region or below Poupart's ligament. If such an abscess is opened, its course will prove more rapid and its healing will be sooner and more final than is the case with the cold ab- scess of spinal caries. On the whole, the outlook is not positively bad in case of tuberculosis of the retroperitoneal nodes. A great many patients recover permanently from the disease, especially if they have the benefit of rigorous out-of- doors treatment. Tumors of the retroperitoneal space are not infrequent. Malig- nant tumors rarely are primary there, while malignant metastases can be treated on general palliative principles only. . On the other hand, benign tumors are often removed from this region and offer brilliant opportunities for radical surgery. The commonest tumors of this class are lipoma, fibroma, myxoma, and similar growths from the subserous tissue. They may arise from behind the solid viscera in the loins, or within the mesentery or omentum, and may attain great size. I saw recently the fragments of a large fibrolipoma removed by Edward Reynolds. The total mass, as it lay in a dish, appeared to be as great as a seven-pound baby. These tumors are found in persons of all ages, and may cause serious symptoms through pressure on the abdominal organs^dyspepsia, mal- nutrition, extensive wasting, pain, and marked abdominal deformity. Rarely there may be obstruction. The only method of treatment is radical excision; and since the diagnosis is necessarily obscure, the sur- geon will generally open the abdominal cavity and remove the growth through the peritoneum. Often one must dig it out piecemeal. If the intestinal tumor involve the mesentery, one must be careful not to damage the intestinal blood-supply. Tumors of the omentum may be removed intact, with the omentum itself. Retroperitoneal cysts are about as common as the solid tumors. The rare echinococcus cyst is secondary, and is found within the peri- 16 242 THE ABDOMEN toneal cavity proper, its favorite seat being the omentum. We occasion- ally find primary cysts, especially in the mesentery. These primary cysts are classed by Hahn as serous cysts, chyle cysts, and blood cysts. They are felt as rounded, tense movable tumors in the region of the navel. They may grow very large, reach the pelvis, and become at- tached to the uterus and other organs. The intestines lie in front of these cysts. The symptoms of retroperitoneal cysts are not noticeable until a considerable tumor has formed, when the patient will often suffer grievously from intense abdominal pain, dyspepsia, constipation, and obstruction even. A rare form of cyst is the epithelial variety, developing in the mesentery, from the remains of the omphalomesenteric duct. Remains of the Wolffian and Miillerian ducts may develop into cysts,* and may possibly be removed through a lumbar incision, without an opening through the peritoneum. The treatment of the more common cysts consists in opening and evacuating them, and removing as much as possible of the cyst-wall, without damage to vessels; then stitching the remains of the cyst-wall to the abdominal wound and packing the cavity. Perfect healing follows. An epithelial cyst must be removed entire, otherwise a fistula will per- sist. An echinococcus cyst cannot be removed, but must be opened and drained. Teratoma of the peritoneum is a rare condition, and the growths are classed by Lexer as simple and complex dermoids, fetal inclusions, and teratoid mucous tumors. Simple dermoids are found in the mesen- tery or omentum, or in the loin behind the peiitoneum. Complex der- moids spring from the ovaries or misplaced testicles and are found in the pelvis. Fetal inclusions lie between the layers of the transverse mesocolon or the omental bursae. Teratoid mucous tumors are either solid or polycystic, and contain tissue from all three embryonic layers. These curious growths generally may be easily removed through abdom- inal section. You will see from the rough sketch I have given in this chapter how numerous, complicating, elusive, and confusing are many of the condi- tions of disease originating in the peritoneum itself or beneath it. Nearly all these diseases have intimate relations with functional derangements of the abdominal organs, so that it is necessary for the surgeon, when con- fronted with abdominal disease, to bear in mind the possibilitj' of the peritoneal or extraperitoneal origin of the sj-mptoms which he studies. 1 See also F. B. Douglas, Retroperitoneal Cysts, Jour. Amer. Med. Assoc, Decem- ber 22, 1906. CHAPTER IX PTOSIS OF THE ABDOMINAL ORGANS— THE ABDOM- INAL WALL In this chapter I shall treat two subjects of widely different moment —abdominal ptosis,^ a common condition, which may complicate and exaggerate other abdominal diseases; and diseases and injuries of the abdominal wall, common enough conditions, but of relatively minor concern. ABDOMINAL PTOSIS Abdominal ptosis is a subject of great importance. I shall not at- tempt a discussion of all its phases, but I shall point out briefly what clinicians may do to relieve the symptoms and the condition ptosis itself. Incidentally, too, I must say a word on the general subject of the etiology of ptosis, as there is a good deal of misunderstanding of that matter, so various are the views of sundry writers. Virchow long ago recognized visceral ptosis, and movable kidneys have been observed for many years. In 1881 Landau wrote a mono- graph calling attention to the importance of movable kidney in women. Glenard, however, in 1885 was the first to show clearly and distinctly that by ptosis of the abdominal organs one may explain on anatomic grounds a group of clinical symptoms hitherto regarded as purely func- tional. Glenard maintained that sufferers from these functional dis- orders are cured of their dyspepsias, backaches, and neurasthenias through relief to the ptoses found in their cases. He gave the name " enteroptosis " to the most common assemblage of derangements which he w^as accustomed to find; namely, to ptosis of the intestines and stomach combined with a prolapsed right kidney. This combina- tion of lesions has been called Glenard's disease. The term " splanch- noptosis" is applied to prolapse of all the abdominal viscera — a very rare condition. Some German writers and others recently have used the term " splanchnoptosis" in place of the older and more common term, enteroptosis. The displacement of single organs is designated by special words, " gastroptosis," " nephroptosis," " hepatoptosis," " splen- optosis," etc. Properly, the term '' enteroptosis" should be employed to describe prolapse of the intestines alone, but I shall follow the com- mon usage as established by Glenard. Briefly, ptosis of the abdominal organs is due to a relaxation of their supports, so that they sag from their places. The consequent dragging upon vessels and nerves brings about certain changes in the circulation 1 Parts of this chapter are borrowed from Surgical Aspects of Digestive Disorders, 1907, by J. G. Mumford and A. K. Stone. 243 244 THE ABDOMEN and innervation of organs, especially of those organs in the female pelvis. So the uterus may be forced out of place, and further distress- ing symptoms may result. Moreover, ptosis of the intestines removes an important sup})ort from beneath the upper abdominal oi'gans. To distinguish cause, and effect is difficult often, so closely are the various organs bound up together and dependent upon one another, antl the clinician, according to his bias, is wont to regard a patient as a gastric, gynecologic, intestinal, or nervous case. The underlying causes of ptosis are still in dispute, so diversified are the conditions found, and so great the range of symptoms accompany- ing them. In explanation of ptosis Glenard suggested weakness of the abdominal nmscles and a loss of intra-abdominal pressure or tone, which permits the stomach, intestines, and kidneys to sag. Some writers go further and suggest that the displacements are congenital, while others put the blame upon improper clothes, especially on corsets and the bands of heavy skirts; writers point out also the disturbing effects of pregnancy, exaggerated often by extensive rupture of the perineum. After considering these statements and studj'ing many patients, I cannot but believe that all such explanations are plausible, but that rarely does any single explanation suffice. J. E. Goldthwait, in 1909, in a series of brilliant papers, showed how the faulty posture of growing children and of women and young girls tends to weaken the skeletal supports and to place at a disadvantage the ligaments and muscles of the abdomen and back.^ Most women among us wear their clothes without regard to h}'gienic considerations. They hang heav}- skirts by narrow bands from their waists, so that a drag is brought upon the intestines, which lie in the lower part of the abdomen. The crowded intestines, in turn, press upon the pelvic organs beneath them. Most corsets tend to exaggerate the waist-line; they crowd down what is below, and push up what is above. Straight-front corsets do not push the abdominal contents downward, as do the old-fashioned corsets, though straight corsets even may produce other unpleasant changes in the anatomy'. Often, and fortunately, however, straight-front corsets, when properly applied, may suffice to correct enteroptosis. In the course of physical examina- tion of elderly women, it is not uncommon to find a permanent furrow made in the costal margin by corset pressure. In view of these facts one cannot but conclude that bands, heav}- skirts, and corsets are etiologic factors in ptosis. One encounters other cases in women whose symptoms all date from childbirth. Of such persons it is probable that many of the dis])lacements were present previously, but did not become troublesome until after the labor. The onset of such s3-mptoms may date from the birth of a first child, or may be due to a precipitate or difficult and instrumental delivery. So there are many and various causes of abdominal ptosis. 1 J. E. Goldtlnvait, The Relation of Posture to Human Efficiency and the Influ- ence of Poise upon the Support and Function of the Viscera, Boston Med. and Surg. Jour., December 9, 1909, et seq. ABDOMINAL PTOSIS 245 It is striking, however, that in spite of this frequency of anatomic displacements, syvi])torns of ptosis are relatively rare. Glenard errs, for no man who has served in a clinic for women would be willing to agree with him, when he implies that all palpable kidneys are pathologic and cause symptoms. What, then, is the process in the development of ptosis? One can- not say definitely that in this or in that begins the vicious circle causing prolapse of the abdominal organs, yet in general terms one m.ay use some such description as the following: Owing to structural peculiarities, to flabby abdominal muscles weakened by severe illness, to improper clothing, or to pregnancies, the normal abdominal tension is diminished; the transverse colon is loosened, usually at the hepatic flexure, and sags downward; it crowds the coils of the small intestine, so that they in turn press upon the pelvic organs. With the loss of abdominal tone the whole colon then tends to collapse, and this collapse extends even to the rectum, so that there is no longer a dilated rectal ampulla behind and below the uterus. The muscles of the pelvic floor lose their resisting power, the uterus settles, and the coils of the small intestine are crowded still farther into the pelvis. There ensue modifications in the shape and position of the pelvic organs, and one finds a prolapsed, retroverted, and retroflexed uterus, and the various combinations familiar to gynecologists. The stomach follows the intestines, for it no longer receives their normal support. As the stomach sinks, the aorta is left uncovered for several inches above its point of division. It may be palpated and may be seen to pulsate even. Indeed, this pulsation is often disagreeable and annoying to the patient. Sometimes the sigmoid flexure becomes dilated with retained feces as a result of intestinal prolapse. The gut may expand greatly, and in the course of time may develop a tendency to volvulus. Conse- quently, intestinal obsti-uction may ensue, and unless this is relieved by high enemata and postural devices, there may supervene rapidly a strangulation demanding operative relief. In such case the condition of the patient may permit a palliative operation only; the operator may untie the obstructing twist and possibly may hold it by sutures, so that the volvulus will not return. When a patient suffers from re- peated similar attacks, increasing in severity, operation must be done to anticipate strangulation. At the operation it may be necessary to resect a portion of the dilated bowel; for often resection alone promises a permanent cure. So after palliative operations, one may be obliged to perform a secondary operation of resection. Let us now consider prolapse of the stomach, which follows the intes- tines in their fall. Its descent is favored, also, by the weight of its con- tained food and by the pressure of corsets and bands tending to stretch the other supports which hold it in a more or less vertical position nor- mally. Consequently, the greater curvature of the stomach sinks grad- ually, and the organ approaches the horizontal. This new position results in its dragging on the pylorus and the first portion of the duode- 246 THE ABDOMEX num in such a way as to kink the hinicn of the pylorus and to impede the passage of food into the intestines. A certain amount of gastric motor insufficiency is, therefore, induced. These conditions cause a further descent of the stomach, because motor insufiiciency results in its being kept loaded longer than usual. Gas-foi-mation and stomach distention result, as well as a frequent tendency to hypei'acidity, with the attendant possibilities of ulcer formation. It is said that this last danger is especially to be feared when floating kidney is associated with gastroptosis. As the general ptosis jDrogresses the stomach descends into the ab- dominal cavity until its greater curvature is well below the umbilicus. What is more to the point, for diagnostic purposes, the upper border of the stomach will then be low in the epigastric region. Ptosis of the stomach may exist without giving rise to an}- dj-.speptic symptoms; indeed, gastroptosis does not necessarily imply gastric dila- tation. That a prolapsed stomach may be normal in size can be demon- strated b}^ the examination of young and thin women. Moreover, moderate motor insufficiency ma}- exist without associated dilatation. Frequenth', in the case of a markedh' prolapsed stomach, when dyspep- tic symptoms are present, they nm}' be relieved quickly b}- a proper diet, proper exercises, and massage. One will find gastric dilatation added speedih- to prolapse in those cases in which dyspeptic s3'niptoms are not checked by proper treatment. The prolapsed stomach drags on the pj-lorus, so that there results a per- manent kinking and narrowing of the p}'lorus. These cases of stomach ptosis, plus dilatation, must be studied carefully if one would recognize the presence of the two associated conditions, ptosis and dilatation. Evi- dence of stasis and an increase in the amount of h3'drochloric acid are present, except occasionally in long-standing cases. The capacity of such a stomach is increased. In the case of such a stomach there exists a genuine pjdoric stenosis — a stenosis as baneful as that caused by a cicatrized ulcer. Some form of operation is needed for the cure, and the choice of operation should be governed by the rules laid down in Chapter IV. Moreover, special operations have been devised for ptosis of the stom- ach. The gastrohepatic ligament, stretched by the descent of the stom- ach, has been shortened by Beyea and sundry other surgeons. They pass sutures so as to bring the pyloiTis close up to the under surface of the liver. The first suture includes both the cap.sule of the liver and the outer coats of the stomach. Beyond this point the gastrohepatic lig- ament and the lesser omentum are infolded so as to raise the stomach and make its upper border resume the normal position. It is suggested that one should fasten up the colon at the same time, else will the stomach lack its old support beneath. Of all the abdominal organs subject to ptosis, the kidney receives most attention — more attention, relatively, than it merits. The wisdom of routine operating for nephroptosis is in dispute. In a routine series of 272 women recently examined clinically at the Boston ABDOMINAL PTOSIS 247 City Hospital Larrabee found that 112 cases, or 41.5 per cent., had mov- able kidneys. At the Massachusetts General Hospital in 1904 Pratt looked for ptosis in all cases coming to his clinic, and found that 96, or 32 per cent., out of 271 women were the subjects of movable kidney. Such has been the experience of many others. Nephroptosis in men is more frequent than is commonly supposed. Floating kidneys have been found in children. Most women with movable kidneys are unaware of renal disturbance; such symptoms as they have are not referred distinctly to the displaced organ. On the other hand, though a patient have a kidney prolapsed in the first degree only, that errant kidney may cause severe symptoms. The case is parallel to that of a patient with a breaking-down plantar arch of the foot. When a foot is beginning to break down, the resulting symptoms may be severe enough to call urgently for relief. So with a kidney beginning to slip. Rarely, indeed, will slight displacements of the kidney require operation, but the physician must not forget that operation eventually may be demanded. When slight displacements cause acute symptoms, one will find often that the ptosis is due to an injury, to a fall, a strain, or a wrench of the bod}^, or to heavy lifting. A prolonged bicycle ride has been known to induce acute symptoms of nephroptosis. In making the diagnosis, assure yourself that the kidney is at fault, and that you are not dealing with a lesion of the sacro-iliac joint. Another aspect of renal ptosis is that presented by a kidney long recognized as floating, and hitherto harmless, which, on a sudden, causes severe and distressing symptoms. The symptoms may be so serious as to suggest appendicitis; and, seen after the acute symptoms have sub- sided, there may remain so much local tenderness as to puzzle the physician and leave him in doubt whether the appendix or the kidney be at fault. Clinicians talk of " Dietl's crises" as characteristic of floating kidney. DietFs crises are supposed to be due to a twist or kink in the renal vein. Some experimenters believe a kink in the ureter to be the more usual cause. Whatever the explanation, it is a fact that in a number of cases in wdiich there is a floating kidney there are repeated attacks of pain and distress. These attacks, or Dietl's crises, begin frequently with a sense of weight and discomfort below the border of the ribs and near the me- dian line; sometimes the first symptoms are pain in that region, and nausea followed by vomiting. If the symptoms persist, the affected area soon becomes tender, so that one suspects peritonitis. Often the patient experiences palpitation of the heart; the symptoms become very dis- tressing; sometimes the mental condition suggests hysteria. The crisis may persist unabated for several days, or it may last but a few minutes. Frequently one may replace the kidney and relieve the sj-mptoms by removing the clothes, by posture, and by manipulation, the patient being in a hot bath if necessary. The experienced observer will notice that these symptoms are simflar 248 THE ABDOMEN to those seen in the gall-stone attacks caused by a calculus attenij)ting to engage in the cystic duct, but not passing out of the gall-bladder. Such hepatic colic is relieved usually by measures similar to those just described. It is associated with no other distinctive features of gall- stone disease, as jaundice or tumor of the gall-bladder. Recurring renal crises make life a burden. The unfoitunate victim never knows when or where the attack may seize her. When it comes, she must be prepared to loosen her clothes, apply heat, and call for the masseuse. As the prolapsed kidney may come in contact with the bile-passages above, so it may drop upon the appendix below. The appendix lies in its path. We have told how one may mistake a tender kidney for a diseased appendix; more than that, an errant kidnej- niay actually irritate the appendix and so cause a chronic appendicitis. So we nmst stud}' carefully the nature of recurring pains in the renal-appendix region. Renal crises do not kill chronic appendicitis may become acute and lethal at any moment. Inflamed retroperitoneal lymph-nodes and stone in the right ureter also may give rise to symptoms suggesting renal ptosis or appendicitis. A. T. Cabot pointed out that hematuria may result from ptosis of the kidney. Sometimes the bleeding is profuse and alarming; sometimes it is slight, but constant. For this hematuria we must operate ; and when we have the kidney exposed and in hand, we must not forget to look in its pelvis for a small calcareous scale which the x-ray has not shown. The treatment of floating kidney involves the treatment of general abdominal ptosis in a great many cases. One must study all the symp- toms of the patient. Often one must perform an exploratory operation in order to make a diagnosis. By anchoring the kidney, biliary and appendiceal symptoms will be relieved frequently; therefore, when the symptoms are complex and obscure, it is well, for the sake of explora- tion, to open the abdominal cavity in front. Thus mistakes will be avoided. So there are certain invalids, few in comparison with the num- ber of persons with displaced kidneys — certain invalids who really do have so much trouble from persistent hematuria, from the frequency of their renal crises, or from the constant dragging sensation and the burning pain along the line of the iliohypogastric nerve that they merit operation. The patient may, indeed, be nervous and irritable — what wonder! — but the pain and discomfort are constant and are found in the same location always. The true neurasthenic element is lacking. Such a patient may be a permanent invalid, nearly bedridden, alwaj's debarred from prolonged exertion, and cut off from the possibility of earning a livelihood. Operation will generally relieve the sufferer, and her chance of cure by operation is very good indeed. But most displaced kidneys do not require an operation. In order to replace the prolapsed organs, lay the patient on her back, with the hips elevated — in a modified Trendelenburg position; manipulate and knead the organs into place, — stomach, kidney, or intestines, — and then bind them in position with the bandage. ABDOMINAL PTOSIS 249 What bandage shall be used? There is the difficulty. There has been a great deal of discussion of that question, and experiment and failure to find the correct bandage. Here is a simple device, which I have found satisfactory: Apply a roller bandage to the abdomen just as one would apply a roller bandage to the arm. The abdominal roller should be of flannel, cut straight, 6 inches wide, and from 6 to 10 yards long. Before beginning to apply it see that the patient is properly elevated and that the viscera are rolled up toward the dia- phragm. Begin bandaging by taking a binding turn about the patient's thigh; then quickly, smoothly, and firmly bandage the abdomen from pubes to ensiform. The bandage must lie fairly tight at the bottom of the belly, but looser at the top. It fits perfectly; it feels snug and secure. The patient will experience relief almost instantly. Fig. 133. — Showing two of the four suspension sutures passed through reflected and attached layers of capsule proper, without penetration of kidney substance. The two companion sutures passed on the opposite face of the kidney are not shown (Edebohls). If this bandage is satisfactory and the patient wishes to go on with such treatment, the physician may have constructed an easily applied belt, but the patient will find no apparatus so comfortable as the simple roller bandage. The straight-front corset, properly fitted, is favored by many clinicians and is successful. There remain those few cases which bandages do not relieve; in which, if the kidney is obviously at fault and its fixation is demanded, the surgeon had best operate. He should approach the renal region through a lumbar incision. Many different operations have been devised and advocated for anchoring the kidney. The commonest error is to fasten that organ too high. Normally, the kidney has an excursion of from 1^ to 2 inches, so that it is well to anchor it at the low^est point of its normal excursion. If 250 THE ABDOMEN fixctl too high, it "svill continue to l)e the subject of pain and \vill be more easily pounded loose by the moving liver above it. Cut down upon the kidney through the back on the outer side of the quadratus lumborum muscle; tear thiough the fatty capsule; pull the kidney out of the wound; split its fibrous capsule from pole to pole, and decapsulate the organ nearly to the hilus; then pass silk or chromic- gut stitches (it matters little which) through the loosely hanging cap- sule, as indicated in the illustration, and thus swing the kidney by capsule and stitches from the back muscles. By emplo3'ing these mea- sures you will not penetrate and lacerate the kidney tissue.' Then close the wound in the back b}' la^^ers. These operations on the kidneys are facilitated by placing a hard roimd bolster beneath the upper por- tion of the abdomen, as the patient lies on his belly. The fixed kidney Fig. 1-34. — Edebohls' kidney air-cushion, and patient in position for ojioration. may break away from its new attachments if the patient moves about too soon. It is my custom to keep him on his back, or on the affected side, wuth the head low, for at least three weeks after the operation. In the few properly selected cases foi- which one does nephropexy the results are gratifying. Pain is relieved, and the constantly recurring dyspeptic symptoms are banished. In the chapters on Diseases of the Liver and the Spleen I have dis- cussed ptosis of those organs. Suffice it hei'e to remind the I'cader that wandering spleen is I'are — rarer than floating liver; that removal of the spleen generally is necessary for cure, and that as yet in spite of many ingenious devices for anchoring the liver, we have not developed a treatment altogether satisfactor}- for the distressing condition, hepato- ptosis with the associated displacement of other organs. AVhen con- ' This is essentially the operation of Edebohls. THE ABDOMINAL WALL 251 fronted with sucli general i)toacs, tr}- first the abdominal bandage I have described in thi.s chapter; have the patient wear it dail}', and have it applied with the patient in a modified Trendelenburg poi^ition. Such treatment gives comfort, even when it does not cure. THE ABDOMINAL WALL Diseases and injuries of the abdominal wall find their place in books of surgery, and of late years this subject has been given much attention by painstaking writers. For my own part, I cannot see that such lesions, with two or three exceptions, deserve special attention, because injuries, inflammations, and new -growths of the abdominal wall are much like similar phenomena elsewhere. The practitioner should remember the general anatomic structure of the abdominal wall — how it is massive and unyielding behind, thin and elastic in front, with the anterior surface of the lumbar vertebrse nearer to the umbilicus than to the skin of the back in average individ- uals. The broad-lying muscles and dense aponeuroses of the abdominal wall favor the limitation of inflammations to special planes; and the gridiron-like arrangement of the muscles as the}^ he one above the other seems assigned ingeniously to streng-then the wall and prevent the development of hernise, even after severely lacerating wounds. The greatest interest in injuries of the abdominal wall centers in the possibility of lesions to the underlying viscera. That is a matter which we have discussed in Chapter II. Contusions ^ of the wall are frequent and may result in extensive tearing of muscles and the formation of great hematomata. The symptoms are usually slight, and the treatment consists in absolute rest and the application of cold. Sometimes it is necessar}^ to aspirate off collected blood. The prescribing of rest is essential mainly because it is not always obvious whether or not the underlying viscera are in- volved. Penetrating and lacerating wounds of the abdominal wall should be treated thoroughly. The patient should be etherized, if necessary, the wound opened and explored carefully, cleaned, and sewed up, with or without drainage, depending upon the amount of laceration and soiling of the parts. If several layers of muscle and aponeurosis are damaged, the wound should be closed in layers, with careful approxi- mation to avoid subsequent hernia. Inflammation of the abdominal wall is a somewhat favorite topic with writers, and here again the significance of the lesion is important mainly on account of the possibility of damage to deeper structures. These inflammations may be superficial or deep. If superficial, they may often be cured by the Bier treatment, hy vaccine therapj', or b}- hot applications merely; but if obstinate, and especially if pus has formed, the abscess must be opened and evacuated. JJhi pus, ibi 1 See Charles L. Scudder, Contusions of the Abdomen, Boston Med. and Surg. Jour., May 2, 1901. He gives a valviable bibliography. 252 THE ABDOMEN evacua, holds true here as elsewhere. The infections deep in the alxlom- inal wall may be of serious consequence, as they may involve such im- portant localities as the prevesical space or the region about the kidneys. The evidence of such deep infection is two-fold — constitutional and local. There is a '' pus temperature," high at night and low in the morn- ing, with a corresponding variation in the pulse-rate, constant leuko- cytosis, debility, wasting. Locally, there is increasing swelling, with pain and tenderness, except where the inflammation is confined by dense aponeuroses. In the case of deep inflammation, thorough ojK'uing with drainage is imperative. There may be special forms of chronic inflammation, \\ith ulceration of the abdominal wall, from such infections as tuberculosis;, syphilis, and actinom3'-cosis. Actinomycosis especially is interesting. It comes usually by way of the intestinal canal. The gut becomes adhei'ent to the parietes; the disease spreads outward; fistulse may form, and an extensive involvement simulating malignant disease may I'esult. In Chapter II is described a case which I saw recently in the hands of a colleague — one of those cases which has all the gross appearance of sar- coma involving the intestine and the abdominal wall. The case seemed hopeless; but extensive dissection of the abdominal wall showed the mass to be an inflammation arising from the intestine, through which an infecting fish-bone had penetrated. The general forms of inflammation must be treated on general principles. Tuberculosis of the parts may be cureted, dressed with iodoform, and the patient given an out-of-doors life. S3'philitic ulcers must be dressed with iodoform or aristol, and the patient given full doses of potassium iodid, 20 to 90 grains daily. The treatment of actinomycosis is not purely operative: we open up fistulse and dissect out involved tissue, and I supplement the operative treat- ment by the method of the Be van clinic — " where a relatively large number of cases have been treated lately (and), excellent results have followed the use of copper sulphate administered in a quarter-grain pill, three times a day, and irrigation of the focus, when possible, with a 1 per cent, solution of copper sulphate." Tumors of the abdominal wall are of three main varieties — cow- nective-tissue tumors, desmoids, and epithelial tumors. The connective-tissue tumors ar'e angionmta, fibromata, lipovrnta, and sarcomata. They must be treated by removal. The lipotnata are the most common; they are usually well incapsulated, and can be easily removed by splitting and enucleation. Desmoid tumors are the most interesting growths in this region. They spring from tendinous tissue, such as the aponeui'oses or the transverse tendinous tissue of the recti muscles. These tumor masses usually are hard, and creak on being cut. The cut surface glistens and shows numerous fibrous bands crossing each other at right angles. Sometimes the tumors contain cysts. They are usually found in women, the proportion of women to men being as 9 is to 1 ; and most of the women affected are those who have borne children. Desmoids are usually found near the median line and are single. They must not be THE ABDOMINAL WALL 253 conf()un(l(Hl with fibromyoniatti of the round h'gament, which may grow within the inguinal canul. 'J'he .'•;y7tiptovis of desmoids ai'c ckic to pressure onl}', for the tumor may reach a considerable size, and interfei-e with the action of the intestines and bladder. The treatment of desmoids is their complete removal — they do not give rise to metastases, and the only point of interest in their removal is the control of hemorrhage, which may be considerable. Epithelial tumors of the abdominal trail ai'c not uncommon. Der- moid and sebaceous cysts occur near the umbilicus, and can be removed easil}' under local anesthesia. Primary cancer occurs also in this region, and should be removed radically. Secondary cancer from the abdominal organs sometimes involves the abdominal wall. Echinococcus is rarely a disease of the abdominal wall. It gives rise to locaHzed swelling, malaise, and wasting. The only rational treatment is incision, evacuation, and removal of the sac, if possible, or its packing with gauze to promote granulation from the bottom. Pendulous abdomen scarcely deserves to rank as a disease, but it is a condition sometimes submitted to operation. A vast, flabby, low- lying mass of fat in the abdominal wall may cause invalidism, practic- ally, and may be removed. Malformations of the umbilicus and urachus are not infrequently subjects for surgery, and the commonest form of malformation is faulty closure of the vitello-intestinal duct. The vitello-intestinal duct, by which the bowel of the embryo communicates with the yolk-sac, disappears usually at about the eighth week of fetal life, but it may per- sist and result in sundry abnormalities, such as fistula at the navel, diverticulum, or cyst. Such an abnormality may be evident when the umbilical cord drops from a new-born infant, or a fistula may develop weeks later. If one of these embryonic passages exists, it springs always from the small intestine, usually from the lower third of the ileum. If the duct is closed inside the abdomen, but persists in the umbiHcal cord, there will remain, after the cord falls, a tumor discharging mucus from its surface — hence the misnomer, enteroteratoma. If the malformation is not extensive or specially troublesome, it may be treated by palliation. Sometimes cleansing lotions, applica- tion of the cautery, and close strapping of the wound may cause an ob- literation of the fistula. It is not wise to perform upon a new-born baby an extensive radical operation for such a deformity. If mild measures do not avail, a radical operation may be done later — after the sixth month of life. Dissect out the umbilicus, explore the abnormality, remove the duct from the intestine, and close the intestinal wound in the ordinary way. The operation is a major one, and may be fatal. A somewhat similar malformation of the urachus sometimes exists — the communication between the urinary bladder and the allantois. This urachus or duct becomes obliterated early in embryonic life, but may remain patent and discharge urine at the umbilicus after birth. Sometimes partial obliteration of the urachus occurs, so that there develops a blind fistula in some portion or a cyst of the urachus. More 254 THE ABDOMEN rareh' similar conditions may be brought about after birth and are associated with or dependent on some obstruction to the normal out- flow of urine through the urethra. AA'ith all these conditions there may be a coincident cystitis. Treatment must overcome obstruction to the urethra; it must cure the cystitis, and must remove the patent urachus, by some such operation as we emplo}' in dealing with the patent vitello- intestinal duct. Infections and inflammations about the umbilicus arc common, especially in the new-boru, and the most frequent cause is filth — a neg- lected collection of sweat and dirt in the umbilical pit. The obvious remedy is cleansing, antiseptic washes, poulticing, and incision if neces- sary. At any period of life an inflamed umbilical fistula may develop, for the umbilicus is the thinnest portion of the abdominal wall, and is a favorite seat for the escape of pus from an intra-abdominal abscess. Such a fistula, depending on its origin, may also discharge feces, urine, or bile. It may close spontaneously, on which account any radical operation for its cure should be delayed for six months at least. Tumors of the tunbilicus are not uncommon. These are the inflammation tumors — the granulomata of infanc}' and the papillary fibromata of later life. A granuloma is sometimes called an umbilical fungus; it must be distinguished from an enteroteratoma, which does not present granulations, but is covered with mucous membrane. The granuloma may be cured by cleansing and touching with silver nitrate, or it may be snipped off with scissors and the wound di'essed with dry gauze. The papillary fibroma of adult life is a firm tumor with a pedicle. It may grow as large as a walnut, and may become maligiiant. It must be excised thoroughly. Connective-tissue tumors of the umbilicus occasionally are reported, but they are rare, especially the non-malignant forms. Sarcoma or fibro- sarcoma is somewhat more common than the benign forms of connective- tissue tumors. Epithelial tumors of the umbilicus have been mentioned already in this chapter. The foregoing paragraphs make plain the fact that there is now a con- siderable literature on the abdominal wall, but there is no great interest in the matter, and with the exception of those curious abnormalities and malformations connected with the umbilicus, the subject merits no more than a cursory discussion. PART II FEMALE ORGANS OF GENERATION CHAPTER X THE UTERUS The general surgeon sees and treats uterine disease, in spite of the fact that gynecology has long been regarded as a specialty. I do not propose to deal elaborately with gynecologic problems in the following three chapters, but to discuss briefly the more important lesions of the female organs of generation. The uterus, tubes, and ovaries are abdom- inal organs, often involved with diseases of other organs, often them- selves subjects for radical operations which every surgeon must under- take. ANATOMY The anatomy of the pelvic viscera is important, but in this brief treatise we have space for a few suggestions only. Surgeons are wont to regard the topography of these organs from two points of view — that from above through the abdominal wall, and that from below through the pelvic floor. It is needless to discuss the anatomy of the abdominal wall as one approaches the uterus from above, though I cannot forbear referring the reader to Max Brodel's beautiful plates in Howard A. Kelty's Operative Gynecology. Suffice it to say that the patient should be placed in the Trendelenburg position, whenever work through an abdominal wound is to be done in the pelvis. By the aid of that position, the intestines — usually the ileum — may be easily held up out of the pelvis. When the beginner approaches the normal uterus, he is surprised to find it Ijang at an apparently unusual depth, far from the abdominal wall. It is in a position of ante version, with the rounded cone of its fundus behind the sj-mphysis. Grasp the fundus with double hooks and draw it up into the wound, when you will see three important structures centering at either side of it, and enveloped in the broad ligament — three structures: from before backward, the round ligament, the Fallopian tube, and the ovarian lig- ament. The bladder lies independently- in front of the womb; it seems to be part of the abdominal wall, for it is outside of the peritoneum, and should have been emptied so as to cause its disappearance, almost, before the operation. The rectum, more clearly defined than the bladder, 255 256 FEMALE ORGANS OF GENERATION drops straight tlown behiiul the uterus. The uterosacral hganients spring from the ix)sterior aspect of the uterus and pass on cither side of the rectum to their sacral attachments. Now, if j^ou dissect carefully I'ig. 13."). — I'atii'iit in I'rciult'lfuliuii;' llCl^^^Bh\k^ji /■K^ofei?=^^^ their edges. This mucous border may be secured later Fig. 152. — Sutures, two buried (after H. A. Kelly). Fig. 153. — The cervix after all the sutures are tied on both sides (H. A. Kelly). by a few superficial catgut stitches which cannot interfere with healing in the depths of the wounds. As a result of this operation j-ou will secure a normal, well-formed cervix of proper length. A light gauze sponge is left in the vagina for twenty-four hours to absorb discharges, and the patient is kept in bed for ten days. If dis- charge persist during convalescence, it indicates usually a continuance of endometritis, and suggests the possibility of a breakdown of the wound edges. In case of such a discharge, therefore, it is well to douche out the vagina daily with a weak solution of lysol or plain boiled water. WOUNDS Wounds of the body of the uterus are most commonly caused by instruments; furthermore, the pregnant uterus may be ruptured by a blow or may be crushed, just as the intestines or liver may be ruptured. Such a uterine rupture is followed immediately by a train of alarming DISPLACEMF^NTS 275 sj'inptonis: by hcnioi-rhagc, collapse, and, if the patient survive, by peri- tonitis. As soon as the accident is discovered, the surgeon should open the abdomen, remove the fetus, and clean out and repair the injured uterus. He should treat peritonitis by the methods already described. Perfoiation of the uterus by a sound, curet, or other instrument is a common accident. If reasonably careful, you will not thus perforate the normal, healthy uterus, but in the case of an organ septic or weakened by disease or pregnancy, it is easy to pass an instrument through the uterine wall into the abdominal cavity. Most surgeons have had such experiences, and the sensation, as the instrument suddenly sinks to its handle in a supposedly small uterus, is extremely alarming, As a rule, however, such an accident is followed by no ill effects if the instrument is a clean one. I have myself thus perforated the utems, and have seen it so perforated by others. Do not hastily open the abdomen to repair the damage. In the great majority of cases a minute hole only is made in the uterus, and the wound heals promptly if let alone. Therefore, let it alone. Keep the patient quiet on her back for a week, when all danger will have passed. Rarely a septic peritonitis follows the accident, and in that case the surgeon must open the abdomen and drain it according to the recog- nized rules. DISPLACEMENTS Displacements of the uterus are as common or commoner than lacerations. One finds them in women who have never borne children, as well as in mothers of families and at all ages. Our chapter on Ab- dominal Ptosis (Chapter IX) hints at one of the causes of displacements — a general relaxation of the visceral supports. This applies to all classes of women, but there are other special causes for uterine dis- placements in the case of women who have borne children. Recall the anatomy of the uterine supports. The arrangements are extremely complicated. We were wont to think that the round ligaments and the perineum were the only structures concerned in holding the uterus in place. They are important parts, merely, of a complex mechanism. They alone are quite insufficient for the work. As with all other abdominal organs, the correct placing and securing of the uterus depends primarily upon the proper tonicity and normal relationship of surrounding organs. The natural position of the uterus is one of anteversion, when the rectum and bladder are empty. It moves backward and forward as those organs contract and expand. The uterine ligaments are all relaxed normally; they do not fix the uterus. Excessive backward displacement of the fundus is checked by the round ligaments and the vesicovaginal wall. Forward and downward displacements are controlled by the uterosacral ligaments, and lateral displacements by the broad ligaments. The pelvic floor has those muscles I have des- cribed, and contains structures divided into pubic and sacral segments. The pubic segment includes bladder, urethra, anterior vaginal wall, and bladder peritoneum. The sacral segment includes the rectum, perineum, 276 FEMALE ORGANS OF GENERATION posterior vaginal \vall, and .strong tendinous and muscular tissue. Both segments spring strong!}- from powerful bony supports. So one Fig. 154. — Retroversion (redrawn and adapted from H. Becker). Normal position of uterus, dotted lines showing 1, 2, 3, degrees of retroversion. sees that malpositions of the uterus may be due to numbers of intricate, complicating, and interdependent causes. Remember, too, that dis- Fig. 155. — Anteversion (Kelly and Noble). placements of the uterus do not in themselves constitute disease. Usually those displacements are but the index of other underlying troubles. DISPLACEMENTS 277 Surgeons are called upon to correct three common forms of displace- ment: (a) Backward displacements; (b) forward displacements, and (c) prolapse downwa>-d (procidentia), and all these displacements are wont to be associated, primarily or secondarily, with such complications as metritis, ovaritis, salpingitis, atresia, stenosis, cystitis, proctitis, tumors, etc. So the resulting symptoms may be correspondingly complicated and numerous. Each displacement may have its own special symptoms, which in turn depend on a various etiology. I have mentioned general abdominal ptosis, with which there is always associated general ill health and any of the familiar constitutional affections, such as anemia, TT^tt/, 0,/A, Fig. 156.— Alexander operation. Drawing out round ligament and stripping back investing peritoneum from the broad ligament (Dudley). renal and cardiac disease, rheumatism, venereal disease, diabetes, etc. Uterine displacements may result from these general conditions, or they may be coincident merely, and by their presence add to the woman's misery. Symptoms may be referred to the pelvic organs or to the nervous system. They may be absent at times; they are often influenced by posture, exercise, and diet. One observes dysmenorrhea, menorrhagia, sterility, recurring abortions, constipation, frequent, painful, or copious micturition. There may be sundry neuralgias, hysteria, dyspepsia, headaches, and blurring of vision. The diagnosis must rest upon the 278 FEMALE ORGANS OF GENERATION L Fig. 157. — Alexander's operation — second step. Fig. 158. — Alexander's operation — third step. findings of examination : bimanual palpation, inspection with the spec- ulum, and the passage of the uterine probe. Thus the position of the DISPLACEMENTS 279 uterus, as well as the presence of complicating disease, can be ascer- tained. Retroversion of the womb is illustrated by the figures, and usually we recognize four stages or degrees. Treatment of retroversion is by replacement, by the use of pessaries, or by surgical operation. Operation alone concerns us here. There are many operative procedures. As a preliminary to them all, treat associ- ated conditions. Repair a torn cervix or a lacerated perineum. Remove complicating myomata, cysts, and diseased tubes. Having thus rend- ered the surrounding parts and conditions relatively normal, proceed to fasten up the uterus itself in its proper position of anteversion, after freeing any adhesions which may bind it down, and after stretching or cutting abnormally tight uterosacral ligaments. Fig. 159.- — Alexander's operation. The best measures for fastening forward the uterus aim at shortening the relaxed round ligaments, or at forming new artificial suspensory ligaments between the fundus uteri and the anterior abdominal wall. I use both procedures, and shall describe various methods with some few words of advice to govern the choice.^ Shortening the Round Ligaments Through the Inguinal Canal {Alex- ander's Operation) . — This method carries with it the dignity of custom, authority, and considerable age, but it is often unsatisfactory, and should be undertaken in selected cases only. The plan of the operation is to shorten the round Hgaments through the inguinal canal, and thus to hold up and forward the displaced uterus. 1 See important paper by W. P. Graves on Retroversion and Its Treatment, an analysis of 500 cases, Boston Med. and Surg. Jour., July 4, 1907. 280 FEMALE ORGANS OF GENERATION The patient should be carefully prepared by shaving and scrubbing, as for abdominal section. 'J'he injiuinal canal is then exposed by incising over it, in a line parallel to Poupart's ligament, about two inches above the ligament and starting from the pubic spine on either side. Having discovered the canal, you may slit it up, or nick it in its upper portion over the internal ring and hook out the contents. Among these con- tents lies the round ligament, often considerably attemuited and some- times hard to find. The uterus should then be elevated with the fingers Fig. 160. — Suspension of uterus — step 1. in the vagina, or with a preliminary packing, and in any case such a packing should be left in the vagina for three days after the operation in order to relieve pain and the strain on the ligaments. Having found the ligaments in the canal, one may secure them in various ways, after drawing them fonvard and stripping back the process of peritoneum — the canal of Nuck. They may be doubled upon themselves and sewed into the canal, or the ends may be pushed subcutaneously across the median line and sewed to each other where they overlap. The abdom- DISPLACEMENTS 281 inal wound should then be closed, and the patient should be treated as after any laparotomy, but eighteen days on the back should be insisted upon. This operation is suitable for a young woman with normal uteiiis, free from adhesions and complications. In no other case is it to be recommended. Suspension of the uterus through the vagina is to be mentioned only to be condemned. It is entirely unsuitable when complications exist, and in any case it fastens the utems in a position of abnormal antever- sion, with the great probability of causing pressure on the bladder with distressing bladder symptoms. Fig. 161. — Suspension of uterus — step 2. Suspension of the uterus through abdominal section is the method to be employed in most cases, for through the open abdomen alone can comphcations and adhesions be discovered and treated. No surgeon can determine always the presence and extent of complications b}' bi- manual touch with the abdomen unopened. The methods of operating by the abdominal route are numerous, and I shall describe two of them. The patient should be placed in the Tren- delenburg position, at an angle of about 45 degrees. Peritoneal Suspension. — Find the uterus and free it from all adhesions ; treat appropriately diseased tubes and ovaries, and remove mj'omata; draw the uterus forward into the position of normal anteversion, and with stout silk or catgut stitches passed through the posterior aspect of 282 FEMALE ORGANS OF GENERATION the fundus, fasten it to the peritoneum. Then sew up the peritoneum and repair the abdominal wall by layers. The stitches must be passed deeply through the uterine muscle, using the anterior uterine wall in 3'oung women, the posterior wall if the patient is past the menopause.^ The result of this operation is that the uterus in a few weeks becomes sus- pended from the peritoneum by one or more processes of tissue which form new suspensory ligaments. The objections sometimes urged against this operation — that the new ligaments may become the cause of intestinal strangulation and that subsequent pregnancies are interfered Fig. 162. — Suspension of uterus — step 3. with — does not seem to hold good when the operation is properly performed. Shortening the round ligaments by the intra-abdominal route is an excellent operation, and one which I have performed many times sat- isfactorily, combining the methods of Gilliam, Noble, Mayo, and Fowler. For this operation enter the abdomen by a transverse incision above the pubes, opening through the skin and aponeurosis (Pf annensteil) , taking pains with gauze dissection to strip clean for five inches about the wound the aponeurosis and the underlying recti muscles. Then, with good retraction, split between the recti and open the peritoneum. I favor this transverse incision for entering the abdominal cavitj^, in this and other pelvic operations of lesser magnitude, because it gives a ^W. H. Baker's modification of this operation (commonly attributed to H. A. Kelly) is popular. Baker pass'es two suspension stitches, each at the comua of the uterus. DISPLACEMENTS 283 resulting scar of great strength, while the exposure is ample. Hav- ing opened the peritoneum and relieved the uterus, seek the round liga- ments in the broad ligament and put them on the stretch by hooking them away from the inguinal ring. Then make a new canal for them by drawing them through the border of the recti muscles, and fasten them together in front of the recti, sewing them outside of the aponeurosis, This operation is superior to that of Alexander for two reasons : it enables the operator to explore and treat the pelvis, and to deal with the strong :fui-k o. )^u Fig. 163. — A method of suspending the uterus — step 3. proximal portions of the ligaments, rather than with the frayed-out and weakened distal portions. Moreover, it enables him to secure the uterus in a normal position and to leave it freely swinging, and, under advan- tageous conditions, for a possible subsequent pregnancy. Several of my patients so treated have borne children aften\-ard, while the preg- nancies and labors have been in no way affected b}' the operation. Other methods of shortening the round ligaments within the abdomen are advocated and practised, but I do not recommend them because they depend upon some form of infolding or doubling of the strong portion of 284 FEMALE ORGANS OF GEXERATIOX the ligaments, but leave the ah-eady weak distal attachments in the inguinal canal without reinforcement. Retroflexion of the uterus is commonly associated with retro- version, and is due to much the same causes. Karely, it is congenital. Infections, the pressure of tumors, and too early getting up after childbirth are the main factors in the etiology of acquired retroflexion. The sympto»)s are such as I have already described when s])eaking of retroversion, but particularly one observes painful and difficult defeca- tion, frequent dyspareunia, and constant dragging or bearing-down pain in the region of the coccyx. The onl}^ satisfactory treatment is by opera- tion through the abdomen. Kcmove the causes, straighten the organ after it has been dilated and cureted, and fasten it forward. 164. — Shortening the round liframents. Anteversion of the uterus is a more nearly normal condition than is retroversion, but pathologic anteversion is much rarer than is retrover- sion. When anteversion does occur, it is sometimes associated with path- ologic anteflexion. The causes of anteversion are adhesions, tumors, and metritis. Rarely, it may be congenital. The symptoms of anteversion are trifling, except when it is associated with anteflexion. (See Ante- flexion.) The diagnosis of anteversion is made readily by bimanual touch, when the fundus is foimd to lie against the bladder, with the cer- vix pointing upward and backward toward the sacral promontory. The treatment of anteversion is so closely associated with the treat- ment of its complications, or with the treatment of an accompanying anteflexion, that one must expend one's efforts on finding a remedy for these complications. The old-fashionetl treatment by pessaries rarely DISPLACEMENTS 285 avails an3'thing, for pessaries do not touch the comphcations. Inflamma- tions of the mucosa nmst be treated by dilatation, cureting, and the ap- plication of iodin crystals, dissolved in 95 per cent, carbolic acid. Ante- flexion must be treated as I shall describe in a succeeding paragraph, while para-uterine inflammations and tumors can be reached through abdom- inal section only. Indeed, you will be driven to exploration of the ab- domen in man}^ of these cases, and not infrequently you will find that hysterectomy alone will restore the patient to health. The result of h}'sterectomy in the case of elderly women for years the subjects of pelvic irritation, vesical pain, and frequency of micturition I have often found to be extremely gratifying. Anteflexion of the uterus is not always distinguishable to the tyro from anteversion. Anteflexion means that the uterine body is bent at Fig. 165. — Retroflexion of the uterus (Kelly and Noble). an angle with the cervix. On examination you will find the fundus in apparently normal position, or perhaps tipped over against the bladder, while the cervix points forward into the vaginal canal instead of point- ing backward toward the coccyx in line with the fundus. There may be all manner of variations from this position, and flexions may be com- plicated with versions. The etiology of anteflexion is not always ap- parent. The condition may be congenital and may be due to inflam- mations or to tumors. The symptoms are similar to those of anteversion, with the addition that bladder irritation is apt to be more urgent, and dysmenorrhea more painful throughout the flow, while sterility is extremely common. The diagnosis is made by the sense of touch, while one must appreciate that the fundus is bent at an angle with the cervix. An erroneous diag- nosis of anteflexion is often due to the presence of a myoma in the an- 286 FEMALE ORGANS OF GENERATION terior wall of the fundus — a mjoma which gives to the examiner the impression that this tumor is the fundus itself bent fonvard. Explora- tion with the uterine probe is necessary to correct this false impression. The treatment of anteflexion is palliative or radical. In the case of an unmarried woman or a married woman who has not borne children, whose sterility is evidently due to the flexion, the deformity ma}- be corrected by thorough dilatation and cureting and the wearing of a hol- .Z'- Fig. 166. — Dudley's operation for anteflexion of uterus — step 1. Patient in Sims' position, cer\-ix held down with double hook tenaculum, scissors introduced. low glass stem for several weeks. A previously sterile woman may promptly become pregnant after this operation, and the deformity may thus be cured, but, as a rule, the flexion will return after dilatation and cureting only. E. C. Dudley's operation is one I have practised with satisfaction. It is illustrated by the figures. Dilate the uterine canal and curet it, then perform the following plastic operation : draw down the cervix and divide it backward in the median line, past the uterovaginal attach- DISPLACEMENTS 287 mcnt, nearly to the uteroperitoneal fold; hold the cut surfaces widely apart and deepen the wound in the uterine wall with a knife. Then excise from either side of the cut surface a small triangular notch, as shown in Fig. 167. Fold back the flaps and approxinuitc the cut edges Fig. 167.- — Dudley's operation for anteflexion of the uterus — step 2. The cut surfaces held apart by tenacula. The dotted hnes show wedge-shaped pieces to be removed by scissors, in order to make the cut surfaces more readily fold upon them- selves. Suture designed to fold cut surfaces on themselves, in place, but not tied. from before backward, enlarging and changing the direction of the canal on the same principle as that employed in a Heineke-Mikulicz pyloroplasty. It is well to use silkworm-gut for this suture. As a Fig. 16S. — Dudley's operation for anteflexion of the uterus — step 3. Suture shown in Fig. 167 tied, and additional sutures designed to fortify this one also in- troduced and tied. This ordinarily completes the operation. result of this maneuver the cervix is straightened backward and is made to point in the axis of the fundus. Dudley points out that in some cases there remains an abnormally long anterior lip. 288 FEMALE ORGANS OF GENERATION Descent of the Uterus and Procidentia. — The various malposi- tions of the uterus which 1 have descriljed are frequently associated with a general descent of that organ, and prolapse of the uterus through the vagina, even to the extent of its protrusion through the vulva, is common. After protrusion through the vulva the condition is called procidentia. Procidentia must not be confounded with inveision. Persons with prolapse of the uterus are commonly women who have borne children and have suffered from extensive weakening of the uterine liga- ments and wide lacerations of the pelvic floor. But descent of the uterus is not confined to such persons. Occasionally, one finds uterine pro- lapse in women who have never been pregnant, but whose uterine supports have been weakened by hard work, constant standing, or pres- sure from above. These factors are often found also in the case of women Ajter n.Drodel. Fig. 169. — Complete prolapse of the vagina and utenjs, with retroflexion (procidentia). who have borne children. The figure illustrates the nature of descensus uteri. At first the organ sinks low in the pelvis, assumes a position of retroversion parallel with the vaginal axis, and then falls lower and lower, infolding the vagina below it until the whole uterus drops out through the vulva. There is associated with this prolapse a stretching of the bladder and rectum, so that one finds accompanying cystocele and rectocele. Such uteri are usually found to be heavy, engorged, subin- voluted, inflamed, lacerated, and often the seat of tumors and retention cysts. The symptoms are constant and distressing, as I have already stated when describing the general symptoms of uterine displacements. Furthermore, the presence of the uterus outside the vulva is a continual irritation, while the rectal and vesical distress becomes almost unen- durable. The diagnosis is generally obvious, but if one is in doubt as DISPLACEMENTS 289 to the extent of the descensus, when the patient is lying on her back, he nuiA' reacUly solve the question by having her stand up and strain, when the uterus will protrude to its limit. Treatment of Procidentia. — We need not concern ourselves here with palliative measures, such as replacement and the use of pessaries. Pessaries may be our only resource in the case of old and feeble persons, but the only hope of radical cure lies in some form of operation. Let me warn the student that operations for prolapse of the uterus are often disappointing in the long rim, even after the organ seems to have been effectual}}' secured high within the pelvis. The first desideratum is a Fig. 170. — Primarj' prolapse of the uterus. sound perineal floor, and the repair especially of the strong supporting levator ani muscle. I shall describe this repair in Chapter XII. But even with the perineal floor repaired, a heavy uterus, armed with a long conic cervix and othei'AS'ise unsupported, may still worm its way clown through the tightest perineum. The terms pelvic hernia and perineal hernia have been applied to this condition of prolapse. The condition is properly one of hernia, so that after hysterectomy even one may find a protnision of the abdominal viscera through the weakened pelvic outlet. In severe cases of procidentia, therefore, the surgeon is forced to some form of abdominal operation in addition to his repair of the perineum, and it may be well also to amputate a long cervix. If one be forced ]9 290 FEMALE ORGANS OF GENERATION to open the abdomen, he should carefully ascertain the state of all the abdominal viscera. He should remove tumors and should treat ap- propriately the products of inflammation. Ovarian cysts and uterine myomata are frecjucnt complications of procidentia, and their removal alone may suffice for its cure. If the uterus is small and in fairly healthy condition, anchor it to the anterior abdominal wall. This operation of anchoring is pro])erly called ventrofixation, and is a quite different matter from that ventroauspension which 1 have (lescril)ed. To fix the uterus, denude a considerable patch of peritoneum from its fundus, — a patch as -^ Fig. 171. — Operation for prdcidentia) as suggested byG. W. Crile. Dotted line in- dicates line of incision — .step 1. large, at least, as a fifty-cent piece, — and attach the uterus firmly at the denuded portion to the anterior abdominal wall, passing the stitches deeply through parietal aponeurosis, recti muscles, peritoneum, and uterus. This maneuver results in establishing broad and firm adhe- sions, which should not stretch or allow subsequent sagging of the uterus. If this operation prove unsuccessful, it may be necessary to perform hysterectomy, which may be done either by amputating the uterus through the cervix, or by removing the whole organ and closing the vagina. If the uterus is amputated through the cervix, the shortened DISPLACEMENTS 291 stumps of the round ligaments should be stitched to the cervical stump for extra support of the perineal floor. But, as I have said, total hys- terectomy does not insure the patient against a perineal hernia. To insure against hernia, various operations have been devised, but I recommend that advocated by G. W. Crile, as I have employed it fre- (juently and with great satisfaction during the past fi^■e years. Briefly, his operation is this : Having opened the abdomen, seize the uterus and draw it up; tie off the ovarian arteries; perform a modified supravaginal hysterectomy, leaving long lateral tabs or fish-tails projecting up from either side of the cervix, and suspend the cervix by these long fish-tails, Fig. 172. — Operation for procidentia, after Crile — step 2. drawing them through the bodies of the recti muscles, and stitching them together much as the round ligaments are stitched together above the recti in suspending the retroverted uteiTis. After any of these operations upon the prolapsed uterus a long period of rest and care is needed. These women are usually debilitated from prolonged suffering and their tissues are relaxed and toneless. They have been the subjects of aggravated forms of hernia, which, at the best, have not been adequately repaired or restored to natural conditions, so that convalescence is tedious, demanding special care and upbuilding. 292 FEMALE ORGANS OF GENERATION (\ TUMORS OF THE UTERUS Forty years ago amputation at the hip-joint was the great capital operation of surgery — rare and interesting. It was said that no sur- geon had won his spurs until he had i)erfornied this oi)cration success- fully. Twenty-five years ago ovariotomy took the leading phice in the estimation of operators, and fifteen years ago hysterectomy was to the fore. To-day, surgeons who are busied with new questions are ventur- ing into other fields, but hysterectomy and other serious operations on the uterus still hold an important place in surgical literature. The his- tory of hysterectomy is recent, and every surgeon of fifteen years' expe- rience remembers the use of the Koeberle clamp, and how we fastened the cervical stump outside of the abdominal cavity. But interest in hysterectomy is far more ancient. It was probably practised b}' the Greeks; it was performed in 1560 by Andreas a Cruce; von Langenbeck removed the uterus in 1813; Sauter, in 1822, and sundry other operators, until we come to such well-known moderns as Billroth, von Mikulicz, and Freund. In 1887 Dudley had collected 38 cases by American surgeons, while to-day it is one of the commonest operations known in our amphi- theaters. Myoma The most frequent tumors of the uterus are myomata, which are non- malignant growths composed of non-striated muscle-fibers and fibrous connective tissue. The old term is " fibroid," or " fibromyoma," but, Fig. 173. — Myoma of uterus, showino; greatly distended veins. in fact, all these tumors arise from muscle substance and connective muscular elements, though the fibroid character often may predominate. We do not know the cause of these tumors. They grow during the period of sexual maturity. Rarely they appear before puberty or after the menopause. They are more common among negroes than whites. TUMORS OF THE UTERUS 293 There is no satisfactory evidence that they arise from traumatisim. Myomata vary in size from a pea to a mass larger than a child's head; they may be multiple or single; they may be hard or soft, depend- ing upon the preponderance of fibrous elements and the character of the blood-vessels, for sometimes the veins reach a great size and appear as dilated sinuses. According to the site of these tumors they are designated variously as submucous, intramural, and subserous; they may undergo certain secondary changes: fatty degeneration; mucoid degeneration; cystic degeneration; calcification; septic infection, and malignant changes. Submucous fibroids encroach upon the lumen of the uterus and may ob- struct it or render it tortuous. They may be pedunculated, and hang clown as polypi in the uterus, and they may protrude from the os. Intramural myomata are usually multiple, and often cause an apparent enlargement of the whole uterus, so that the organ may seem to fill the abdominal cavity and distend its walls, giving the appearance of preg- nancy at full term. Subserous myomata may be single or multiple, and may be associated with other forms of myomata — intramural and submucous. Subserous fibroids may appear merely as excres- cences beneath the serosa, or ma}^ be pedunculated. Rarely isolated myomata free in the abdominal cavity have been described. Subserous fibroids may pro- ject from the sides of the uterus and dis- tend the broad ligaments, in which case the}^ are known as intraligamentous m^'omata. Commonly these uterine tumors are in the fundus, but infrequently they develop in the cervix, and they may appear in the vaginal portion only. The s)miptoms of uterine myomata may be numerous and distress- ing, or there may be no symptoms. The disease may first make itself known during a pregnancy, at which time the tumor may grow rapidly. The common and alarming sjanptom of mj^omata \siJiemorrhage. This hemorrhage is due to endometritis, dependent on irritation by the growth. The blood does not come directly from the tumor itself. The flow comes on gradually, not suddenly and profusely, as is the case with hemorrhage from cancer. The patient notices that her menstrual periods come more frequently than common, and that the flowing is more abundant and more prolonged. This condition persists, and the disturbance increases until eventualh" the patient may be the victim of frequent attacks of long-continued and alarming hemorrhage, prostrating her and threatening life even. The advent of the menopause may or may not affect the hemorrhages. Sometimes the tumor shrinks at that period and the hemorrhage ceases. In other cases the menopause seems Fig. 174. — Polypi in uterus. 294 FEMALE ORGANS OF GENEHATION to be the signal for ronowcd activity on tlic jnirt of the tumor, which grows and causes more hemorrhage tiian ever. Fig. 175. — Large submucous myoma (H. A. Kelly). Adapted to removal by abdominal section by splitting open the uterus and enucleating the tumor, and then sewing up the uterine incision. Fig. 176.— Myomata. The symptoms of pressure, traction, pain, and discomfort are next in importance to hemorrhage. The causes and nature of these symptoms are obvious when one considers the position of the uterus and its rela- TUMORS OF THE UTERUS 295 tions to other orp;ans. In most cases the uterus itself becomes somewhat enlarged, although an actual increase in the uterine body is not invari- able. With its associated tumors it may press downward or upward, backward or forward. It may drag or press upon the rectum, the blad- der, the urethra, the vagina, and may interfere with the functions of the intestines and other abdominal organs, for it may become inflamed and set up adhesions. As a result of all these derangements there may be obstinate constipation, frequent micturition, leukorrhea, — dysmen- orrhea is common, — pain in the region of the coccyx or sacrum, colicky stomachache, dyspepsia, headache, nausea, blurring of vision, and many other indefinite abdominal and general nervous symptoms. Fig. 177. — Adhesions to uterine myoma. The diagnosis of uterine myoma is not so easy as would appear. Especially, these tumors must be distinguished from tumors of the ovary and from intraligamentous cysts. Often it is extremely difficult to distinguish a tense cyst from a soft myoma. The common symptom of hemorrhage is not pathognomonic of myoma ; associated growths and extensive adhesions may render obscure the diagnosis to the examining hands. The surgeon should make a bimanual examination and map out the lower portion of the mass with fingers in the rectum as well as in the vagina. He should also endeavor to distinguish a uniform myomatous enlargement of the uterus from a pregnancy— often an extremely diffi- 29G FEMALE OllOAXS OF OEXEKATION cult matter. In this connoction he should ascertain accurately the time, character, and amount of hemorrhage, the condition of the breasts, and the presence or absence of a fetal heart. Pregnancy may be present in a myomatous uterus. The uterine probe is a valuable ad- junct in making the diagnosis of myoma, antl usually it can be employed when the question of a possible pregnancy has been eliminated. The probe will follow the uterine canal often to a considerable depth, — 1, 6, or 8 inches, — and by its means one may demonstrate the relation of the uterus itself to the associated new-growth. Other conditions to be differentiated from myoma are malignant growths, chi'onic metritis, inversions and displacements of the uterus, incomplete abortion, disease and pregnancy in the tubes, and floating kidney. The prognosis of uterine myoma is a much-debated question. Deaver ^ wrote an extremely interesting article on the subject a few years ago, and claimed that the great majority of these cases come to no harm if let alone. It is a fair estimate that of all women over thirty-five years of age 20 per cent, are subjects of these growths, and undoubtedly great numbers of such women have no special discomfort beyond some increase of the normal flowing and some enlargement of the abdomen. As opposed to Deaver's view, many gynecologists assert that every uterine myoma should be removed on account of the danger to life from hemorrhage, exhaustion, and possible malignant degeneration. That question of malig-nant degeneration is extremely important; some statis- tics show that not more than 5 per cent, of these growths become malig- nant. However that may be, every surgeon of experience has seen cases of myoma associated with mahg-nant changes, and in view of this fact one caimot but regard such malignant degeneration as possible in every case of myoma. On the whole, one agrees with Deaver that the majority of myomata do not endanger life, but one should bear in mind the possible dangers and should take his measures accordingly. My own practice is to advise removal of the tumor, the patient's general condition permitting, in all cases in which symptoms are persistent dur- ing the age of menstrual activity ; and after the menopause, if the tunK)r continues to grow, whether or not troublesome symptoms be present. The treatment of myoma uteri is oi3erative, so far as anything more than mere palliation is concerned, though there are sundry traditional and tentative measures which the practitioner maybe tempted to follow. Tonic doses of ergot or ergot and hydrastis canadensis are sometimes of value to control hemorrhage — 15 drops every four hours or oftener. This dosage, combined with an ice-bag over the tumor, may check hem- orrhage and allow of the building up of the patient preliminary to operation. Manipulation of the tumor may sometimes relieve incarcera- tion below the sacral promontory, and so enable the patient to get along with less discomfort and pain. Excessive hemorrhage may be controlled by packing the uterus with gauze or by steaming. Steaming is remark- ably useful in some cases. The technic is to introduce steam drawn from a small " steamer" and carried through a 3- or 4-foot tube, armed 1 Amer. Med., April 15, 1905. TIMOUS OF THE UTERUS 297 with a glass nozzle, through an intra-titcrine speculum, directly into the cavity of the uterus. Let a stream of cold water play over the spec- ulum to prevent its becoming superheated; inject the steam for forty seconds, then withdraw the nozzle for a couple of minutes, and introduce it again for thirty seconds. This treatment brings about a necrosis of the entlometrium and results in thickening and scar formation — enough, often, to prohibit subsequent hemorrhage. Do not waste time with styptics to control hemorrhage, nor weary yourself and the patient with elect roh'sis, which is often dangerous as well as useless. Surgical operations for these myomata may be performed through the vagina or by abdominal section. The latter is preferable in most cases. ]\Ioreover, these operations may be conservative or destructive Fig. 178. — Steamino; the uterus. — that is to say, they may be designed to remove the tumors or to re- move the uterus with the tumors; and in the latter case the removal of the uterus may be total (panhysterectomy) or partial (supravaginal hysterectomy). In addition to these operations, authors have claimed great things for milder measures. Gojttschalk, of Berlin, ties the uterine arteries and claims thus to check the progress oFthe growths. ^Martin ties the broad ligaments, but does not include the uterine arteries. Battey, Tait, and others have claimed good things through the removal of the tubes and ovaries; but such procedures have not borne out their first promise. Vaginal operations have their place in the treatment of myomata, and usually are applicable to small tumors. By the vaginal route one 298 FEMALE ORGANS OF GENERATION may remove sul)niuc()us polypi. By the same route one may remove the whole uterus or may enucleate tumors and leave the uterus. M}' experience with vaginal hysterectomy for myoma does not lead me to recommend this method, although the operation itself may be extremely eas}'. I cannot regard it as a proper routine surgical procedui'e, because it does not allow of a thorough inspection of the field and treatment of complications. The presence of extensive adhesions and inflamed tubes and ovaries may render the vaginal operation extremely difficult, and the ureters cannot always easily be avoidetl. On the whole, vaginal hysterectomy for myoma is as difficult or more difficult than abdominal Fig. 179. — Removal of subserous myoma of uterus. hysterectomy, and the mortality is no lower. I shall describe the technic shortly under the topic Cancer of the Uterus. Vaginal enucleations and morcellation are operations of doubtful value. They are blind, and unsurgical, and they leave the operator in the dark as to possible complicating conditions. Tumors confined to the cervix, however, and pedunculated growths in the uterine cavity should be removed by the vaginal route. For the removal of the latter the wire snare and scissors are generally sufficient, but it may be neces- sary to split up the cervical canal in order to allow of proper handling of instruments within the cavity and the removal of masses choking the os. TUMORS OF THK UTERUS 299 Abdominal Operations. — Myomectomy. — Strangely enough, the con- servative operation of myomectomy came into general use long after the radical hysterectomy had become familiar. By myomectomy we Fig. 180. — Removal of myomata. mean shelling out the myomata, one by one, from the uterus. The operation is so easy in appropriate cases that nothing more than the illustrations are needed to demonstrate it. Open the abdomen; throw Fig. 181. — Uterine polyp removed -u-ith scissors. the patient in the Trendelenburg position; wall off the uterus; pull it to the fore with vulsellum forceps, and enucleate the tumors individually with knife, scissors, and fingers. In properly selected cases the opera- 300 FEMALE OKGAXS OF GENERATION tion is cxtrcMnely easy, aiul the hemorrhagic into the resultin<;- cavities is readily couti-ollcd by buried catgut stitches. Finally, sew iij) the wound in the uterus and suspend the organ if it seems inclined to drop back into an abnormal position, ^^'ipe out the peritoneal cavity; re- place the omentum, and close the abdominal wound. It often requires some nice surgical judgment to decide between myomectomy and hysterectomy. In general terms, myomectomy is preferable in case the nuiss of tumors be of moderate size, and the growths located mostly near the surface of the organ. Myomectomy for submucous polypi may well be done by the abdominal route. The operation consists in splitting Fig. 182. — Ligation of uterine vessels, clamp applied (adapted from Dudley). open the body of the uterus, cleaning out the submucous growths, and treating the inflamed mucosa with the curet and weak carbolic applica- tions. Then sew up the uterus with catgut stitches, which shall not include the mucosa. This operation is eas}^ safe, and extremely effec- tive— a great advance over many old-time dilatings and curetings. Low cervical ])olypi may be removed with scissors or the wire snare. Supravaginal hiisteredoniy is the operation of common choice in cases of myoma uteri, and usually it is not difficult. A'olumes have been written on the technic, and most of our best-known surgeons and gyne- cologists have had their word to say on the matter. AVhen all is said, the operation is simple enough when the pelvic conditions are uncom- TUMORS OF THE ITKIIUS 301 plicated. The abdomen is opened through the left rectus muscle by a liberal incision, large enough to permit of the delivery of the tumor, when the surgeon seizes the mass with strong vulsellum forceps, and, if possible, turns it out through the abdominal wound. Complications may render difficult or impossible this delivery at once. Adherent viscera must be carefully dissected off from the tumor, diseased tubes and ovar- ies must be removed, incarcerated masses must be shelled out of the pelvis, and intraligamentous growths must be freed by splitting the broad ligaments. Having delivered the tumor, the next step is the vitally important one of sec\iring the four sources of blood-supply, the ovarian and uterine Fig. 1S3. — Fish-tail incision for amputation above cervix (adapted from Dudley). arteries, and this rarely is difficult. I prefer to double-clamp the broad ligaments close to the mass and divide the tissues between the clamps. Then dissect off the peritoneum from the uterus about the cervix, just above the attachment of the bladder. Push this peritoneum well do-\^Ti on to the cervix, leaving exposed a broad strip of the cervical muscularis. Then pass a curved threaded needle about the deep-lying uterine vessels and tie tightly. I prefer not to use clamps for these vessels if I can help it, because clamps add to the complication of instruments in the narrow field. In securing the uterine vessels, and, indeed, in all manipulations about the tumor, one should have in mind possible danger to the ureters. These structures often are greatly displaced by myomata, and in the case of extensive intraligamentous growths the ureters may appear 302 FEMALE ORGANS OF GEXERATION to be far out on the side of the tumor. For this reason, in the case of difficult dissections, some operators do their work after having passed catheters through the urethra into the ureters. The vessels being now controlled and the ureters isolated, amputate through the cervix with knife or scissors. I prefer to make a fish-tail incision, which may readily be closed like any other amputation stump, and before closing the stump I rim out the cervical canal with the actual cautery, or swab it with pure carbolic acid. Then close the cervical stump with buried catgut sutures. Draw over it and stitch in place the dissected peritoneum, and complete the operation b\' fastening the stump of the round ligaments into the remnant of the cervix. I. regard this stitching of the round ligaments into the cervix as important for the Fig. 184. — Suture of cervical stump (adapted from Dudley). support of the perineal floor. Sagging of the cervical stump is thus pre- vented and the bladder is kept properly supported. E. C. Dudley ad- vocates sewing the severed stumps of the broad ligaments to each other across the pelvis. This is an excellent maneuver when ])Ossible, but the same end is attained by such a treatment of the round ligaments as I have described. The question of leaving one ovary, or a portion of an ovaiy, in the pelvis has agitated men. It is certain that removal of both ovaries at once from a woman who has not yet passed the menopause results in more serious nervous disturbances than when ovarian tissue is left. After the menopause the removal of both ovaries causes less disturb- ance. TUMORS OF THE UTERUS 303 The aftor-troatmont of these cases is quite simple and consists in the usual care of diet and bowels, with rest in bed for from two to three Fig. 185. — Repair of round and broad ligaments (adapted from Dudley). w^eeks. If the patient be tightly and properly swathed, she may be turned about in bed as soon as she has recovered from ether. Total Hysterectomy {Panhysterectomy). — In a small number of cases the surgeon may think it wise to remove the whole uterus, including the Fig. 186. — Combined panhysterectomy, diseased tubes (Massachusetts General Hospital). cervix, for the organ may be so septic or otherwise diseased as to render the presence of the cervix dangerous to the patient; or the cervix 304 FEMALE OROAXS OF CEXEHATIOX itself may be involved in the new- iadapt(>d from Dudley). TUMORS OF THE UTERUS 313 disease, stitches up firmly the os, to prevent fouling of the wound by- discharges, and with flat vulsellum forceps draws the cervix to the vulva. With scissors or knife he then incises the vaginal mucosa about the cervix and strips it back thoroughly on all sides for an inch or more, when the uteroperitoneal reflection will be recognized by the loose character of the tissues, and by the fact that under the finger the loose tissue slips over the peritoneum. The stripping back should be done with the finger. The operator then seizes with forceps the postperi- toneal fold, which has been stripped loose from the rectum, and nicks through into Douglas' fossa. He enlarges this opening by tearing with L .. - . -A- Fig. 196. — Vaginal hysterectomy — step 6 (adapted from Dudley). the fingers. Then he opens anteriorly between the cervix and bladder in the same fashion. With wide openings before and behind the uterus the surgeon is now ready to control the blood-suppty. In suitable cases this may be done readily by passing the forefinger of the left hand up through the poster- ior opening and hooking down first the left and then the right broad ligament. Secure the ligaments with stout silk sutures, embracing first the ovarian artery, then the uterine artery, and then, behind these ligatures, the broad ligament itself en masse. Having secured the vessels, cut away the broad ligament close to the uterus. Some surgeons, after cutting away the left broad ligament 314 FEMALE ORGANS OF GENERATION drag down the fundus through the left opening, and thus put the right broad ligament on the stretch, when it may readily be secured and cui away with the parts practically outside of the vulva. The uterus having been removed in this fashion, stitch up the jjeri- toneum, bringing together the divided round ligament and broad liga- ment stumps, and then sew up the rent in the vagina. Drainage may be supplied by passing a gauze wick into the subperitoneal space through a small opening in the vaginal vault. These manipulations are facili- tated by having the patient in a motlified Trendelenburg position. Fig. 197. — \'aginal iu-sterectomy — step i (adapted from Dudley). There are certain dangers, difficulties, and complications in vaginal hysterectomy. The operation should not be undertaken in the face of involvement of the para-uterine structures — when the uterus is in any degree fixed, when the broad ligaments are thickened, when the tubes and ovaries are diseased, and when the lymphatic connections and glands are involved. It is by no means easy always to avoid injuring the ureters; the}' have often been cut by experienced operators even. They may be avoided by introducing catheters into them, and b}' clinging closely to the cervix in making the dissection. We are as yet far from being able to remove the utenis through the vagina with such ease and clearness of vision, looking to lymphatic involvements, as in removing the breast and its associated lymph-nodes. TUMORS OF THE UTERUS 315 The presence of the ureters, lying within one-half inch of the cervix, renders almost impossible a wide and sure dissection by the vaginal route. In spite of these facts the vaginal route will always be a favorite route with operators, because in early cases the dissection is easy, the oiKM-ative mortality low, the immediate results briUiant, convalescence short, discomfort slight, and recurrence reasonably infrequent. Abdominal Hysterectomy for Cancer. — This operation is shown by statistics to be more fatal than vaginal hj^sterectomy, but such statistics are misleading, because abdominal hysterectomy is extremely difficult or impossible in the case of fat women, whose thick abdominal walls and densely packed pelves render manipulations difficult or impossible. Fig. 198. — Vaginal hysterectomy — step 8 (adapted from Dudley). Moreover, abdominal hysterectomy is commonly practised in the more advanced and complicated cases. The development of abdominal hysterectomy for cancer of the uterus has been stimulated latel5\ in this countr}- especially, by the researches, practice, and preaching of John A. Sampson,^ but his extremely inter- esting and radical operation has not yet found entire favor with the profession, on account of the difficulty of following his technic without a- resulting high mortality. I am convinced, however, that a more frequent resort to a modified, but still radical, abdominal hysterectomy for cancer of the uterus will result in improving our statistics. 1 John A. Sampson, Jour. Amer. Med. Assoc, October 29, 1904; ibid.. May 20, 1905. 316 FEMALE ORGANS OF GENERATION The Operation. — With the patient well elevated in Trendelenburg's position and the intestines carefully isolated (the maneuver of stitching the parietal peritoneum to the posterior pelvic brim gives a particularly clear and free fieldj, the uterus is removed in nmcli the same fashion as I stated in describing panhysterectomy for myoma — the vaginal vault having previously been opened from below, if you choose. The broad ligaments may then be extensively dissected ; the retroperitoneal space laid open by splitting the broad ligaments; the ureters, iliac vessels, and lymphatics exposed, and all suspicious tissue removed by careful knife Fig. 199. — Abdominal hysterectomy for cancer. The uterus fF) being pulled far to the right, the uterine artery is tied and dissected away from the ureter (Ur) with a mass of pelvic cellular tissue. P is a posterior layer of peritoneum; B, the bladder; C, the cervix; V, the vagina fKelly, after J. G. Clark). and gauze dissection.^ It will not do to remove too thoroughly all the tissues about the ureters, because .such removal results in cutting off their blood-supply, and in consequent necrosis of the ureters. In case of the ureters being involved in the growth or necessarily denuded, they must be resected and implanted into the bladder. The simpler abdominal hysterectomy may be no more effective for a cure than is vaginal hysterectomy; but abdominal hysterectomy 1 The reader should supplement this brief description by studying Sampson's admirable articles. TUMORS OF THE UTERUS 317 does permit a more careful exploration of the field. Whether or not the extensive dissections I have last indicated shall prove of permanent usefulness remains to be demonstrated through time and experience. The after-treatment of these cases, as well as the after-treatment of cases of vaginal hysterectomy, differs in no essential from that fol- lowed in cases of myoma. ^ Vagocuffj Fig. 200. — Panhysterectomy for cancer. Epithelioma of the cervix in grape- like mass. Showing the extensive removal of the uterus and the broad ligaments by the abdominal method (J natural size) (Kelly). There are sundry other diseases and tumors of the uterus, more or less rare and more or less unimportant, which it behooves us to mention in passing. Endothelioma Endothelioma is a malignant tumor rising from the endothelium of the vessels or serous surfaces and closely resembling cancer. It is found in the fundus of the uterus as well as in the cervix, and may extend to neighboring organs. The course, symptoms, and treatment are similar to those of cancer. Sarcoma Sarcoma is rare in the uterus ; it may develop in youth, in maturity, or in old age. Three forms are described: (1) Fibrosarcoma; (2) diffuse sarcoma; (3) racemose, grape-like sarcoma. Fibrosarcoma resembles myoma in its location, though it is encapsu- lated rarely. Diffuse sarcoma may occur anywhere in the uterus, and is wont to invade the whole organ. Racemose is very rare; it generally starts in the cervix, and forms cyst-like masses resembling hydatids. It has been found in children as well as in adults. It grows rapidly and is extremely malignant. 1 For a suggestion for the palliative treatment of uterine cancer see foot-note on p. 848. 318 FEMALE ORGANS OF GENERATION Sarcomatous degeneration of a myoma may occur (spindle-cell sarcoma). One suspects it when hemorrhage from myoma increases; when the tumor grows after the menopause; when the growth returns after removal; when ascites develops suddenly; when cachexia appears rapidly. The symptoms of the various forms of sarcoma are in no way peculiar. Some of the sarcomata grow slowly; some are extremely malignant. Spindle-cell sarcoma, for instance, may not destroy life for many years ; on the other hand, the diffuse, small, round-cell sarcoma is more malignant than is cancer. All the forms suggest cancer, symp- tomatically, but metastases are more numerous and more distant often than is the case with cancer, for the emboli of sarcoma travel by the veins, while cancer progresses through the lymphatics. The treatment of sarcoma is the same as that of cancer. Indeed, it rarely happens that the two are distinguished from each other before operation. Deciduoma Malignum Deciduoma malignum (choriodeciduoma) is an excessively fatal tumor resembling sarcoma. It is often preceded by hydatidiform mole, and occurs commonly between the ages of twenty and forty. It was described so lately as 1889 only.^ The growth is unique, the essential element being a large giant-cell embedded in sarcoma-like substance. But the tumor is epithelial. The growth appears as more or less circumscribed, dirty reddish brown, and friable, with frequent early metastases. The symptoms suggest cancer, but the most characteristic symptom is a profuse hemorrhage occurring after labor or abortion. There is an abundant foul, watery or bloody discharge, often containing hydatid- like moles. There are, of course, the usual constitutional disturbances which we associate with malignant disease. On examination one finds an enlarged uterus, movable or fixed, smooth or nodular. Often the uterine cavity will admit the finger, which detects masses of soft tissue and clots. One settles the diagnosis by the microscope. Nearly 80 per cent, of all patients affected with choriodeciduoma die within six months. The only possibility of cure rests in prompt hysterectomy. In this chapter I have sketched in brief outline the common sur- gical diseases and injuries of the uterus. I have given such a picture as is familiar to the general surgeon — a picture which may help to guide the studies of the undergraduate and the practice of the physician. The numerous comprehensive text-books and systems of gynecology are essential to a wide understanding of these matters. 1 Sanger, A System of Gynecology, Play fair. CHAPTER XI FALLOPIAN TUBES AND OVARIES Disease of the uterus is often associated with disease of the tubes and ovaries, as I stated in the hist chapter. This association is notably- true when injiammations of the organs are concerned, but it is a signifi- cant fact that any disease of the uterus may be found associated with some disease of its adnexa, even though the nature of the disease of the adnexa be something quite other than what is found in the uteiiis. Thus uterine m3'omata may coexist with ovarian cysts, and soKd tumors of the ovar}^ may be associated with uterine displacement and endome- tritis. Cause and effect are often sufficiently obvious. We shall consider inflammations of the adnexa and structures surrounding the uterus, solid tumors and cysts of the adnexa, and ex- tra-uterine pregnancy. SALPINGITIS Salpingitis^ is inflammation of the Fallopian tubes. The anatomy of the Fallopian tubes is interesting, and their development especially is interesting. They are formed by that part of Midler's ducts above the round ligaments. The uterus and vagina are formed from that part of the ducts below the round ligaments, together with the Wolffian ducts. The various uterine structures, mucosa, muscularis, and peri- toneum are continued to the tubes, so that we have an endosalpinx, a myosalpinx, and a perisalpinx. The tubes spring from the horns of the uterus, and lie in the upper portion of the broad ligaments, being from 3 to 5 inches long. Their lengi:h is divided into an isthmus, an ampulla, and a fimbriated extremity. The causation of salpingitis has been already sketched in our last chapter, when we described inflammations of the uterus. By far the greatest number of tubes involved in inflammation are infected from below, and the causes are the common causes of metritis — abortion, labor, instrumentation, gonorrhea, syphilis, tuberculosis. The writers discuss other causes also, among which appendicitis is important, and the acute exanthemata, various constitutional disorders, and the spread- ing of infection from other organs. Trauma — from a fall — cannot cause a salpingitis, though it may aggravate an already existing salpingitis. There are various terms used by writers, and Dudley gives the fol- lowing classification : " L Catarrhal salpingitis — salpingitis serosa. " 2. Purulent salpingitis — salpingitis pumlenta. 1 Salpinx, a tube. 319 320 FEMALE ORGANS OF GENERATION " Catarrhal salpingitis may result in sactosalpinx serosa — hydro- salpinx. " Purulent salpingitis may result in sactosalpinx jjuiulcnta — pyosalpinx. "If sactosalpinx is complicated by hemorrhage into the tube, it is called sactosalpinx ha^morrhagica, or hematosalpinx; this is more com- mon in serous than in purulent infections." Then there is tuberculous salpingitis. The pathology of these various conditions is similar often, and the conditions themselves frequently are impossible to differentiate clinic- all3^ The infecting medium usually reaches the tube through the canal of the uterus, though tuberculosis may be implanted from above or by the blood-stream. The usual phenomena of inflammation take place after infection has occurred — such phenomena as are seen in metritis; but the results are different, because in the case of the uterus there is usually fair drainage, while in the case of the tube the isthmus frequently becomes choked or closed completely. The fimbriated end of the in- flamed tube may remain open, but generally it becomes closed also. When the fimbriated end remains open, tubal secretions flow out and infect the neighboring peritoneum and the epithelial covering of the ovary; so that if there be present a freshly ruptured Graafian follicle, ovaritis may result. Again, infection may penetrate the wall of the tube, even when the fimbriated end is closed. In this case a perisal- pingitis may arise with involvement of all the pelvic \'iscera. A Fal- lopian tube highly inflamed is somewhat analogous to an inflamed appendix, and acute salpingitis is in some degree similar to acute ap- pendicitis—not so deadly, however, because the tube is a stronger organ than the appendix, its infections are less vimlent, as a rule, and walling- off processes are more certain. In advanced salpingitis, however, we do get tubal perforation, peritonitis more or less extensive, adhesions, multiple pus-cavities, and, frequently, a thick, matted, angry mass of viscera, packing tightly the pelvis, apparently impossible of unravel- ment. This condition of inflammatory involvement of the pelvic contents was commonly called pelvic cellulitis, for it was thought that the in- flammation centered in the loose connective tissue about the sides of the pelvis, and in the broad ligaments and para-uterine structures, and that the tube, when involved, was involved secondarily. Doubtless the term pelvic cellulitis is proper enough under certain conditions, but most pathologists now agree that extensive inflammation of the pelvic viscera is commonly secondary to tubal inflammation. Pelvic cellulitis lead- ing to salpingitis even does occur sometimes, through direct transmission of infection from the uterus, by means of lymphatic and venous channels. When this happens, there results, first, a perimetritis with inflammation extending into the adjacent viscera until eventually there is produced a condition similar to that which originates in a salpingitis. Clinically, however, one may often make this distinction, that whereas an extensive inflammation originating in the tube centers there, is there most destmct- SALPINGITIS 321 ive, and spreads from that focus, a pelvic cellulitis, on the other hand, originating in the uterus, involves that organ primarily, submits it to more or less destructive processes, causes para-uterine inflammation and abscess formation, and involves the tubes secondarily only. This distinction may have an important bearing upon prognosis and upon treatment, for a primary salpingitis calls for treatment of the tubes Fig. 201. — Matting of the viscera in salpingitis. directly, while a pelvic cellulitis may necessitate more particularly the treatment of the uterus and the deep pelvic tissues. In the one case it may be proper to operate upon the tubes through abdominal section. In the other case it may be essential to drain a pelvic abscess through vaginal section. But bear in mind always that the two varieties of inflammation may eventuate in producing similar appearances and may necessitate similar methods of treatment. 21 322 FEMALE ORGANS OF GENERATION Hitherto we have been considering the nioie virulent forms of in- flammation. There are the milder forms, catarrhal salpingitis, resulting in hytlrosalpinx and rarely in hematosalpinx. In these milder forms the inflammation remains confined to the tube. The tube and ovary may be involved simultaneously in disease. For instance, we see the conditions known as tubo-ovarian cyst and tubo-ovarian abscess. Such conditions are brought about through the formation of inflammatory adhesions between the tubes and ovaries, a resulting sinus formation from one organ to the other, and the partici- pation of each in the disease of the other. As a rule, inflammation of the ovaries is secondary to inflammation of the tubes; but ovaritis may occur independently of salpingitis, through infection, by means of the Fig. 202. — Tubo-ovarian cyst. The tube above ends in a bulbous extremity fused with the ovary, with only a slight sulcus between them. The ovarian ligament is shown below, leading out to the cystic ovary (path. No. 665., natural size) (H. A. Kelly). lymph- and blood-channels from the uterus or from other organs, among which organs the inflamed appendix is the most common source of infection. The exciting organisms in the case of ovaritis are the gonococcus, the colon bacillus, the staphylococcus, the streptococcus, the pneumococcus, the typhoid bacillus, and the tubercle bacillus. A true primary ovaritis is extremely rare. Symptoms of Salpingitis. — It is often impossible to distinguish the symptoms of salpingitis from those of ovaritis, especially when the ovaritis is a consequence of the salpingitis. Ovaritis due to other causes frequently may be distingviished. However, whether or not the inflammation involve the ovary, you will find the sufferer from salpingitis complaining of pain, dull or Ijurning, constant or remitting, and of localized tenderness. There may or may not be recurring rises of temr SAI-nXGITIS 323 peratiuc, for that depends largely on the involvement of the peri- toneum. Ivxcept for the fact that the focus of infection is in the pelvis, the sym|)toms suggest strongly those of appendicitis. Moreover, it is often impossible to distinguish sharply an acute salpingitis from a chronic salpingitis, since the two constantly run into each other. A chronic salpingitis may become acute at any time, just as an acute salpingitis may become chronic, and in most cases one looks for some s^'mptoms of involvement of the uterus, such as I described in Chapter X. Fig. 203. — Tuberculous salpingitis. The right tube and ovary divided, showing the extent of the disease in the ovary and in the numerous cross-sections of the tube. F.U is the fundus of the uterus, and Ma myoma attached to it. Between the uterus and tb.e myoma is seen a portion of a large sac of an encysted peritonitis. The left tube is distended, convolute, and covered with tubercles; the fimbriated end is swollen and exhibits numerous tubercles. This is preeminently a case for extir- pation of tubes, ovaries, and uterus. (Case of Dr. C. Cone, JMms Hopkins Hosp. Bull., May, 1897, |- natural size.— CuU en.) On physical examination, which should be made bimanually, great varieties of conditions are found. The finger should explore both the vagina and the rectum, when one ma}^ discover all sorts of pelvic masses, from a merely thickened tube and broad ligament to a fixed and enlarged uterus, a collection of exudate filling the pelvis, fluctuating areas, and hard, porky, or brawny tumors. Often it is impossible to differentiate the component parts of this collection, or again one may distinguish satisfactorily the uterus from the tube, and the tube from the ovary, and may map out collections of pus. The diagnosis of chronic salpingitis is founded upon such a his- tory, symptoms, and physical signs as I have described — commonly 324 FEMALE ORGANS OF GENERATION there is an old p;()n()rrhca, iiuule evident perhaj);^ by the eontinuance oi a chronieally (enlarged vulvovaginal gland; there is the story of long- continued uteiine discharges, sterility, dysmenorrhea, a sense of weight, bearing down, tenderness, faihng health, and invalidism. Such a composite picture may have been put together within a few days or weeks, and may have been associated with previously acute symptoms suggesting apjx^ndicitis. In the acute cases one fre(iuently learns of a recent abortion or labor. Or the stoiy may mn over weeks or months, in which case one is apt to suspect rather a gonorrheal infection. All forms of infection may involve all the pelvic organs, and may result in similar pathologic appearances; but the puerperal infections, though frequently chronic, may run an acute and fatal course even, while the gonorrheal affections are those usually followed by chronic disease. When all is said, however, the sur- geon frequently is surprised on oper- ating to see very extensive struc- tural changes out of all proportion to the trifling symptoms. Tuberculous salpingitis is not always distinguisha'ble from the forms I have described. Between 6 and 8 per cent, of all tubal infec- tions are tuberculous. The involve- ment of the tubes may be primary or secondary, and is often a part of a general tuberculous peritonitis. Tuberculous salpingitis also may be chronic or acute. When it is acute, the secretions escape usually through the fimbriated end of the tube, which is open frequently in acute T-. ^^ . rr,, ^ , 1 forms. Chronic salpingitis is con- Fig. 204. — The T-tube. g ^ -^-u- ^ i\ ? fined withm a closed tube. The diagnosis of tuberculous salpingitis is almost impossible of differ- entiation clinically from other forms of salpingitis, though in typical cases of chronic tuberculous salpingitis one finds loss of weight, a hectic temperature, a rapid pulse, frequent amenorrhea, an abdomen little if at all sensitive to pressure, sometimes ascites; and one looks for a history of tuberculosis and the involvement of other abdominal organs. The treatment of all these pelvic infections is divided into medical and operative treatment. I shall not discuss the former further than to say that it consists in improved hygiene, an out-of-doors life, rest, carefvil feeding, tonics, ichthyol suppositories (an extremely useful SALPINGITIS 325 measure), hot packs, hot douches, tampons, and, in the hands of some physicians, pc'lvic massage. The operative treatment of acute salpingitis presents questions for careful judgment. The answer to the question, when to operate, is not so easy as we found it in the case of acute appendicitis. We can lay down no rule that an inflamed tube should be removed at once, as we should say of an acutely inflamed appendix. An acutely inflamed tube rarely threatens life immediately. The inflammatory process is relatively slow, and the formation of protecting adhesions is almost certain. In a great majority of these cases rest, douching, and cold applications will relieve the symptoms and localize the process, so that a delayed oper- ation, if any, may be anticipated. Rarely one sees fulminating peri- tonitis from an acutely inflamed tube. On the other hand, with the subsidence of acute symptoms and with the establishment of a chronic salpingitis one finds often that non-opera- tive treatment fails to cure. Operative treatmerU of salpingitis is undertaken by two routes— the vaginal and the abdominal; and the old discussion as to choice still waxes and wanes. Without entering into the controversy I prefer to state that my own practice is to approach the disease through the vagina when pus-sacs are to be drained— especially pus-sacs which present m the vagina. The operation is not difficult. With the patient m the lith- otomy position and the vaginal canal widely exposed, the surgeon mcises Douglas's pouch behind the cervix, where pus usually collects; intro- duces his finger, explores the cavity, evacuates the pus, and drains with a T-shaped rubber tube. This operation takes no account of the more radical procedures sometimes advocated— the breaking up of adhesions, the opening of the general peritoneal cavity, the search for and the bringing down and packing of isolated, distended tubes, and the re- moval of organs. In any vaginal operation for drainage the surgeon should avoid injuring the ureters. Effective drainage is established by the operation I have_ described, and in nearly all cases subsidence of inflammation follows, with reason- ably prompt healing. The cavity should be washed out daily, and should be kept open with a gauze drain after the first week— so long as the discharge continues. Inflamed tubes and ovaries are not removed by these measures, but it is astonishing often to observe m how short a time exudates and masses will disappear, until the pelvis is returned to a nearly normal condition. Later, if distorted and crippled organs remain the surgeon may think it wise to open the belly from above and deal with those organs by the abdominal route. Often at such a secondary opera- tion he will be surprised to find the remaining structural changes ex- tremely slight. , ^r^„lo7. Abdominal section for pelvic inflammation was an extremely popular procedure a few years ago. We now employ it more mtel igently and m selected cases-in cases of chronic salpingitis, rather, of long standing and indolent inflammations; of extensive involvement of organs, witn their matting, crippling, and disorganization. The operation may be 326 FEMALE OKOAXS OF GEN'KRATION easy, or long, difficult, and dangerous. It is a simple matter to remove an isolated, thickened, functionless tube. It is far from simple to clean up and set right a pelvis filled with dcnscl}- matted masses of viscera. For the sake of clearness I shall describe an easy operation — the removal of an inflamed tube, without complications. I shall then describe a difficult operation. Simple Salpingectomy. — Trendelenburg's position is essential to com- fortable work in the pelvis. The Fallopian tube must not be rough]}' isolated and removed, as is frequently done by inexperienced surgeons. After carefully packing back the intestines seize the fundus of the uterus with vulsellum forceps and bring it up into the wound, which should be large enough to admit of comfortable manipulations. Separate light adhesions by gauze sponging, taking pains not to damage intestines or to rupture a distended tube. Tie off with catgut the infundibulopelvic Fig. 205. — Incision for removal of diseased tube from uterus. ligament between the ovary and the wall of the pelvis. Then ligate a small section of the broad ligament where it joins the uterus, close below, but not including the tube. These two ligatures control the blood- supply. Next seize the tube and ovary and excise them with scissors. Excise the whole tube, dissecting it out from the fundus of the vtenis, and close the uterine wovmd with catgut stitches. Do not tie off the tube and leave a stump. ^ Such a stump may be a focus for future trouble. We 'The surgeon should have in mind possible future pregnancies. In this con- nection M. Storer writes in a personal communication: " I often cut the tube off an inch from the uterus and stitch the peritoneum to the endothelium, in those cases in which a subsequent pregnancy is de.'^ired. Sometimes these patients conceive later. If the tube is thickened all the way, I excise a wedge-shaped piece out of the fundus of the uterus; but if the uterine end be apparently normal, I hesitate about making it impossible for the patient to have another child — and I have had very few secondary operatiojis." SALPINGITIS "^27 now have to close the rent in the broad ligament. I usually sew it up with a buttonhole catgut stitch. Dudley sews it up by a shortennig method first converting the rent into a V-shape and approximatmg the distal to the proximal end. Either method is good, but Dudley's method doubtless furnishes the better support to the uterus. If the tube and ovary have been removed in this manner without encountering complications and without soiling the peritoneum, the abdomen may then be closed, and a perfect convalescence expected. Complications.— A discussion of the varying comphcations and difficult situations which may arise in clearing up a pelvis thoroughly infected and containing matted masses of, viscera would involve us m many words. I shall i7idicate merely procedures to be followed, while the reader must bear in mind the intricate conditions I have already described. The presence or absence of pus is the leading question to be considered; next, the extent and intricacy of adhesions. Moreover, the pus may be sterile or infectious, and adhesions may be shght, or they may implicate the entire thickness of a viscus. If extensive parametric abscess be associated with pyosalpinx, whether or not the two communicate, it is best first to drain the abscess from below, as 1 stated when treating of vaginal section, though many competent sur- geons advise and practise completing the operation and removing the tube through the vagina. Without entering into this controversy 1 must record my objection to the vaginal operation. It is impossible by the vaginal route to deal satisfactorily with densely adherent or possibly torn intestines or with a diseased appendix. ^ With the patient in the Trendelenburg position, and with the viscera carefully walled off so far as possible, one proceeds to the abdominal operatio"^ by gently and patiently disentangling the masses One searches for' the points of least resistance, ^^'^^^^^^fl^^^ll '"^^l yielding sulci, wipes out fluid, separates and packs off f^'^^-^^^'^^^^^ repairs intestinal, bladder, or ureteral rents if they occur Thus grad ually the mass is broken up and the individual «^-g?;j^^^7f ,^^^^^^^^^^ When this is accomphshed, there usually r em ams still an mteresting problem to solve. Shall the uterus be removed with the tubes or shal it be left? The answer to this question depends upon the extent ot the metritis. This is a point which we considered m the las. chapte but in general terms be it said that it is safer to remove a highly inflamed uterus than to leave it as a source of continued ^^^^^^^^^^^ T^V^Hhe ing of the French school is that uteri should always be removed ^ hen the acfnexa are removed. I do not subscribe to this view. J^^^^l^J^^^ finds a case so difficult that completion of the operation ^^^^^P^^^^^^^^^ on account of the imminent danger to hfe, through spi;ead « " ectmn and destruction of intestines. In such a case it is well to^^^"^ ^ ^^^J gauze the pelvis both from above and from below. After some days o leeks of such drainage it may be possible to complete the operation at a second sitting. Hemorrhage is another complication which mvist caie fully be guarded against. Extensive oozmg is ;°™«^^ , ^^^^^^^^'^^^ vessels are often so obscure that they cannot be found. Secondary 328 FEMALE ORGAN'S OF GENERATIOX hemorrhage is not infrequent. I have had three shocking cases of death from secondary hemorrhage follow this operation. lor these reasons, as well as on account of the septic condition of the deep field, abdominal drainage is essential after all operations for complicated pelvic inflam- Fig. 203.— Diagram of the condition after removal of the right tube and left ovarj', showing the distance separating the remaining tube and ovary (Kelly). mations. I use and am satisfied with a cigaret drain passed through a stab-wound above the pubes and carried to the bottom of the pelvis. The abdominal wound is then closed tightly. By using this stab-wound Fig. 207. — Diseased tube: area of obliteration excised. one renders the abdominal wall strong and tight, little liable to hernia in the scar. In case of tuberculosis of the tubes they should be removed and the pelvis drained. When the uterus as well as the tubes is con- cerned in the tuberculous process, total hysterectomy should be per- TUMORS OF THE FALLOPIAN TUBER 329 formed, unless extensive tuberculous involvement of other abdominal organs renders hysterectomy obviously futile. Conservative operations on the tubes and ovaries have been advocated for the past twenty years. Schroder and Martin, as well as the Amer- ican Polk, were advocates of such operations; while Dudley, Kelly, Morris, Storer, and Reynolds have made valuable contributions to the literature of this subject. In brief, these operations aim at pre- serving some small but sound portion of diseased ovaries, and at re- establishing the lumen of twisted and obstructed tubes. I shall have a word to say shortly in regard to the conservative treatment of ovaries; as for tubes, there is abundant evidence that in certain cases when damaged they may be restored to function, for after such operations conception and pregnancy have occurred — results impossible under the conditions founcl to exist before the operation. The obliterated end of a tube may be resected or rendered patent, and attached to a func- Fig. 208. — Conservative resection of tube, operation complete. tionating ovary. Obliterating cicatrices are excised from the ampulla, and end-to-end suture performed, restoring the tube's lumen; while an ingenious operation, similar to that of the Heineke-Mikulicz pyloroplasty, will overcome tubal stenosis, TUMORS OF THE FALLOPIAN TUBES There are tumors of the Fallopian tubes — infrequent , little regarded. Inasmuch as the tubes contain the same histologic elements as the uterus, they may be the seat of tumors similar to uterine tumors. It is ex- tremely difficult or impossible to distinguish clinically these growths from tumors of the ovary. Generally, the diagnosis is made on the operating table. There are tubal papillomata springing from the adenomatous tissue of the mucous glands. Such growths are a menace to life because they are liable to invade the peritoneal cavity, there to spread rapidly and 330 FEMALE ORGANS OF GEXERATION involve other organs. The possible presence of such a tumor is always to be considered when one is dealing with pelvic neoplasms. This is a strong reason for removing all pelvic growths. If possible, a Fallopian papilloma should be excised promptly and entire. If it has invaded the peritoneum, its removal generally is impossible. One finds the abdom- inal cavity filled sometimes with these papillomatous growths from the tubes — -growths easily bleeding and giving rise to a considerable accumulation of ascites-like, bloody fluid. Such growths, if unchecked, prove fatal rapidly. There are cystomata of the Fallopian tubes — retention cysts of the mucous follicles found generally in the vestibule. There are rare myomata. There are carcinomata and sarcomata of the tubes — infrequent diseases, primary in the tubes almost never. A'eedless to say, they should be removed early, if at all. THE BROAD LIGAMENTS The broad ligaments may be the site of solid tumors and cysts less frequently than of inflammations. Rarely malignant disease may develop there, but benign disease is not uncommon. You will find cysts, mvomata, lipomata, dermoids, cancer, sarcoma. Cysts are the interesting broad-ligament growths. They are dif- ficult to distinguish clinically from ovarian cysts. The terms 'par- ovarian and intraligamentous cysts are applied to them. In almost all cases they are developed out of the remnants of the Wolffian duct, which lies in the broad ligament below the Fallopian tube. These cysts are commonly unilocular and contain a thin, straw-colored fluid. If they have not become inflamed, they niay be peeled out from the broad ligament. The symptoms of parovarian cysts are in direct relation to the size of the C3\st and the pressure it exerts on neighboring organs. Pres- sure may cause general pelvic discomfort, varying pains, dysmenorrhea, and irritation of the bladder and rectum. The treatment consists in enucleating the sac, and this generally can be accomplished. Some- times, when there are extremely complicating adhesions, one may be obliged to pack the cavity after the cyst's removal and allow healing by granulation. In the rare cases of pedunculated parovarian cysts the surgeon usually ties off the growth. Rarely supravaginal hyster- ectomy must be our resource in dealing with intraligamentous cysts. In operating avoid injuring the ureters. Hydrocele of the round ligaments is a condition analogous to hydrocele of the spermatic cord. The accumulated fluid is in the canal of Nuck, and appears as a fluctuating tumor at the internal ring, or even lower, in the mens or the tip of the labium. This condition cannot always be differentiated from inguinal hernia. The treatment consists in laying open and removing the hydrocele sac. Solid tumors of the broad ligament usually lie between the peritoneal THE OVARIES 331 folds, though rarely they may become pedunculated. They may grow to any size, if non-malignant, though nowadays they are usually discovered and removed when small. It is almost impossible to dis- tinguish them from ovarian or uterine tumors before the abdomen is opened. The only treatment is operative. Open the abdomen either from above or through the vagina. Certain writers direct that the vaginal route invariably be chosen. Such advice is not consistent with good surgery. \Micn difficult and complicating conditions exist in these cases, as in other forms of pelvic disease, it may be necessary to clean out the pelvis by removing the uteiiis and its adnexa. Dermoid cysts have been found occupying the broad ligament. Their syinptotns and treatment are quite similar to those of solid tumors. Solid tumors of the round ligament ^ are rare. They may develop in the canal or within the abdomen. Except when large, they cause no special symptoms, but they should be removed when discovered. Varicocele of the broad ligament is not infrequent; indeed, dilated veins are often found in various parts of the pelvis, associated with tumors and pregnancy. The common varicocele of the broad ligament is a dilatation of the veins of the ovarian pampiniform plexus. This varicocele generally is caused by an arrest of involution of the vessels following labor, by inflammation of the veins, or by the existence of long ovarian veins unable to propel the great weight of blood. Con- stipation and uterine displacements are other causes. The left ovarian vein frequently enters the left renal vein and may be obstructed by an overlying, heavy sigmoid flexure, loaded with feces. Such are some of the causes of these varices, though the etiology is not always clear. The patient suffers from dull, aching pain in the pelvis when she stands. Menstruation is wont to be frequent. The diagnosis may be obscure, though rarely, in thin subjects, one may palpate the varicocele. The only satisfactory treatment is abdominal section and excision of the veins. Malignant disease of the broad ligament is uncommon, and when present, is usually secondar}^ to disease of the uterus and other organs. Extirpation of such disease of the ligaments seldom is possible. The Ovaries The ovaries are organs of such vital interest to patient and surgeons that ihey deserve more than the short notice I can give them in this chapter. They are interesting physiologically as well as pathologic- ally. Their disease or removal means more than sterility to a woman, but we must limit ourselves to a brief consideration of their surgical diseases. OVARITIS Ovaritis as a complication of salpingitis is common, but the surgeon must be careful to distinguish true ovarian inflammation from ovarian hj-peremia. The latter condition may be caused by malpositions, by 1 Barton Cooke Hirst and Norman Knipe report^ an extremely interesting case of this nature in Surg., Gyn., and Obstet., 1907, vol. iv, p. 715. 332 FEMALE ORGAXS OF GENERATION twists of the ovarian pedicle, and by sundry traumatic irritations. Acute ovantis is almost always due to the streptococcus. The gono- coccus is more apt to give rise to a periovaritis. Tuberculous ovaritis is not especially uncommon. It arises from infection transmitted through the Fallopian tube, through a tuberculous vaginal lesion, through the peritoneum, or rarely through the general circulation. It is not always possible to make a positive differential diagnosis of the above-named forms of ovaritis. All of them are characterized by general or localized pelvic pain, by dysmenorrhea, by local tender- ness, by enlargement of the ovary, by its displacement, b}- adhesions, and sometimes by evidences of a general infection. Frequently the tubes, the uterus, and the peritoneum are involved in the process. One must distinguish also l>etween acute and chronic ovaritis. In typical cases acute ovaritis is characterized by an enlarged, tense, elastic ovary, with or without adhesions, together with the associated condi- tions I have mentioned; while chronic ovaritis is usually an outcome of acute ovaritis. In chronic ovaritis the ovarj- is at first swollen and hard; later, nodular and cystic, with symptoms of a less intense charac- ter, such as I described when speaking of chronic salpingitis. In general terms inflammations of the ovary are so closety associated with inflammations of the tube that we must consider both organs when we come to the subject of treatment. Treatment. — If the attack is acute, general symptomatic treatment should be followed: absolute rest, the giving of saline laxatives, and hot vaginal douches and glycerin tampons on alternate days, with an ice-bag over the groin. Such treatment is indicated especially in the case of gonorrheal infection. When the inflammation is due to the streptococcus, the symptoms are wont to be more severe, and pus-for- mation is more certain, so that vaginal drainage may be our resort. In the case of chronic ovaritis palliative measures, such as I des- cribed in the last paragraph, may suffice for a time; but for permanent cure we must resort usually to an operation. This subject of what operation to perform on chronically inflamed ovaries is intricate and difficult, because the operation depends largely for its success on the condition of the tubes. For the lazy surgeon it is easy to answer the question by removing both tubes and ovaries. Often, however, such radical procedures are needlessly crippling, and conservative treatment may be followed by a brilliant, satisfactory result. In any case a portion at least of one ovary should be preserved in order to obviate an artificial menopause, and to forestall the so-called reflex neuroses which so commonly afflict young women deprived suddenly of both ovaries. After the menopause the ovaries may be removed with more freedom. Conservative operations on the ovaries consist in the puncture and cauterization of cysts, the excision of scar tissue, and the stitching of the ovary into proper relations with the open tube. If the tube itself is diseased, one may treat it by some such plastic operation as I have described in a previous paragraph. If the ovary is tuberculous, it should be removed, together with TUMORS OF THE OVAltlES 333 the corresponding tube, and the operation should include complete extirpation of the tubal isthmus, with suture of the resulting wound in the uterus. If the ovary alone is removed, the pedicle should be Fig. 209. — Repair of broad ligament after removal of ovary — step 1. carefully secured by suture and the rent in the broad ligament repaired, after the fashion I described when speaking of removal of the tubes. TUMORS OF THE OVARIES Twenty-five years ago ovariotomy was the magnum opus of ab- dominal surgeons, and to-day even the operation creates a surprising amount of interest, for ovarian tumors generally can be removed entire. Fig. 210. — Repair of broad ligament — step 2. and their removal releases the patient from painful, distressing invalid- ism, and retuiTLS her with promptness and completeness to vigorous, normal health. 334 FEMALE ORGANS OF OENEUATION As with tumors elsewhere, ovarian tumors are of ^reat variety, though ovarian cysts are the tumors most famihar and most satisfac- Fig. 211. — Repair of l)road ligament — step 3. tory in treatment. Ovarian tumors are l^enign or malignant. Primary cancer is the commonest form of malignant ovarian disease. Fig. - 12. I'^normous nvarian eyst. A\'('iglit, 12N pounds (Massachusetts (Jcucral H()s])itan. There are sundry forms of ovarian cysts: Follicular cysts are pri- marily dilated follicles, the result of previous inflammalion. They TUMORS OF THE OVARIES 33^ develop on the surface of the ovary, are of slow growth, and vary from the size of a bean to that of an adult head. These cysts may be single or multiple; gradually they destroy the ovarian tissue and appear as large water-bags containing straw-colored fluid or fluid turbid with changed blood. Cysts of the corpus luleuni develop in a ruptured follicle. They grow slowly, and do not become so large as the follicu- lar cysts; again, unlike the follicular cysts, they are usually single. They contain clear, serous fluid. Tnbo-ovarian cysts develop in ovaries and tubes at once, but they are priniar}' in the ovary; they are of fol- licular origin, and involve the tubes through inflamed adhesions. Rarely Fig. 213. — Papillomata of both ovaries seen from behind (Kelly). On the left side a series of mulberry masses are seen hangino; from a delicate pedicle attached to the Fallopian tube; on the right, the ovary is transformed into a mulberry- mass, and inside a cyst two masses are seen sprouting. do they exceed an orange in size. They contain a clear fluid also, and are unique in this respect, that they may communicate with the cavity of the uterus, through which exit occasionally their contents maj^ escape. Proliferating or neoplastic cystoniata are more rare. They are not retention cj^sts, but are true new formations, papillarj' or glandular, according as they contain papillary growths or not. Their contents may resemble mucin (pseudomucin) or may be serous. The papillary cysts may grow to a great size, and are most common in women who are unmarried or sterile. Such cysts generally are single, though they may be multiple. The fluid, when drawn off, is found to be of a thick, rop3^ consistency. The serous cysts are less common than the papillary 336 FEMALE OKGAXS OF GENERATION proliferating cysts, nor do they grow so large. These serous cysts often develop within the folds of the broad ligament, and are wont to form adhesions with neighboring organs. We must note especially the proliferating cysts. Though histo- logically benign, they develop rapidly, and in their removal portions may become detached and implanted elsewhere in the peritoneal cav- ity. There they grow and nmltiply, forming metastases. Sometimes malignant degeneration occurs, when either carcinoma or sarcoma may develop. So these proliferating cysts are to be dreaded. If you open the abdomen to remove an ovarian tumor, and find in the peritoneal cavity free fluid, bloody and serous, look for a proliferating cyst ; remove it entire, if possible, but give a guarded prognosis. Dermoid cysts are the least common of ovarian cysts. Usually, they are pedunculated, though sometimes they may develop within the folds of the broad ligament. They grow slowly and rarely exceed in size an adult head. Commonly they are single, and contain various substances: fat-like material, hair, teeth, and bones. The probability is that these growths have their origin in the ovule, which possesses the elements needed for the development of human tissues and structures. Solid tumors of the ovary are rare also. They are usually rounded, smooth, and pedunculated, though they too may lie in the broad lig- ament. Often they are associated with cysts. Of these tumors, fibro- mata are the mo.st common. Myomata are rare. Within the fibro- mata myxomatous changes may occur and calcareous matter may be deposited. We find primary cancer of the ovary, medullar\^ carcinoma, and adenocarcinoma. Medullary carcinomata, like other solid ovarian tumors, are both pedunculated and intraligamentous. The adeno- carcinomata are made up of cystic tumors, usually pedunculated, at- taining the size of a child's head, frequently adherent to other organs, with papillary excrescences. It is not always easy at once to distin- guish the adenocarcinomata from non-malignant proliferating cysts. Secondary malignant growths in the ovaries often result from uterine neoplasms. There are also ovarian ejidotheliomata, springing from the blood- and lymph-vessels of the ovar\'. Like other malignant diseases they occur in middle life, but may develop in childhood. Hematoma of the ovary must be mentioned — a distinct tumor reach- ing the size of a small orange. It is rarely made out before operation. The symptoms of an ovarian tumor vary with the nature of the growth and with its size and attachments. Most benign tumors cause trouble from their size and pressure only, though frequently, in the case of small ovarian cysts, the patient is aware of some pelvic discomfort, and may complain of exaggerated menstrual pain. An exception to this lack of frequent pain is the case of an ovarian tumor with a tuisted pedicle. There is a great literature on this subject. Small ovarian tumors, as well as large ones, may become twisted, the twist being usually from left to right, or as the hands of a watch move. The ped- icle may twist through many degrees, depending upon its length and TUMORS OF THE OVARIES 337 mobility. Twists of four or even five complete turns have been re- ported, though usually one complete revolution is enough to set up acute symj)tonis and send the patient to a surgeon. These twists cause stran- gulation of the vessels, engorgement of the tumor, and agonizing pain, which may be spontaneously relieved after a time by a partial untwist- ing. The twist may occur independently of menstruation. The great danger of the condition lies in the probability of a firm permanent twist resulting in gangrene of the tumor. ^ Another form of non-malignant tumor which gives rise to pain is the dermoid cyst. Ovarian cysts may rupture and apparently disappear. As a general thing, however, ovarian cysts reach a considerable size before causing pronounced symptoms; these symptoms may be amenorrhea or other menstrual disturbances, but the pronounced symptoms are due to mechanical pressure. One hears of bladder, rectal, and renal disturbances, with great swellings of the abdomen, of edema of the legs, of hemorrhoids, and sometimes of ascites. In the case of solid benign tumors the symptoms vary little from those which I have just described, but malig- nant tumors cause pain, cachexia, wasting, and the other conditions common to all late malignant disease. The diagnosis of ovarian ttunor may be easy, or it may be extremely difficult. The history and symptoms count for little, as tumors of other organs, especially of the uterus and tubes, give rise to similar symptoms. We must depend on our physical examination. A typical ovarian cyst may be handled bimanually. It feels like a rounded, smooth, elastic, movable mass, occupying the pelvis or lower portion of the abdomen. Nowadays these tumors rarely reach the great size shown in the old text-books as classic. Surgeons discover ovarian cysts early in their growth, and take them out long before the tumor fills the abdominal cavity. If the cyst is large, it may be confounded W'ith ascites or other causes of abdominal distention. Note, however, that free fluid in the abdomen settles in the flanks and gives rise to shifting dulness when the patient turns. On the other hand, a great ovarian cyst is shown by central dulness which does not shift. But the small tumors usually found are mapped out as small tumors. Some- times they are so soft and flabby as not to be felt. Sometimes they are so hard and tense as to be mistaken for solid tumors. Every surgeon has cut down upon an ovarian cyst under the mistaken impression that it was a myoma of the uterus. Extensive adhesions and concurrent new-growths complicate further the diagnosis. Solid ovarian tumors also may be distinguished as discrete, movable masses, or they may be mistaken for tumors of the uterus, tubes, or broad ligaments. Preg- nancy may complicate and confuse the diagnosis. Rapidly grow-ing tumors, rather than tumors of slow growth, are likely to be malignant. Sudden increase in size, associated wath acute pain, is usually due to torsion of the ovarian pedicle. Pregnancy may be distingiiished by the patient's vomiting, by enlargement of her breasts, softening of the cervix, placental bruit, and perhaps by fetal heart-sounds. Uterine 1 See article by M. Storer, Boston Med. and Surg. Jour., November 5, 1896. 22 338 FEMALE ORGANS OF GENERATION tumors are usually distinguished, among other signs, by elongation of the uterine canal, as shown by the exi)loring probe. In spite of all tests, with which the literature of this subject abounds, the most experienced surgeon may make mistakes. In this case, es- pecially if synijitoms persist and become aggravated, one nmst resort to an exploratory operation. The prognosis of ovarian tumors untreated is illustrated by the abundant and curious literature of the last century, and the prog- nosis varies as greatly as do the gi'owths of which that literature treats. In general terms, benign tumors produce slowly developing invalidism, sterility, neuroses, exhaustion, impairment of the functions of the abdominal organs, wasting, and a lingering death after many }'ears. Malignant disease of the ovaries advances rapidly in the familiar fash- ion, with metastases, extensive involvement, cachexia, and death in from one to two years. Furthermore, one may never say when the benign may become the malign, so that in every case extirpation of the growth is the surgeon's duty. Ovariotomy. — The subject of removal of ovarian tumors marks one of the proudest chapters in American surgery. Ephraim McDowell, of Danville, Kentucky, in 1809, was the first surgeon to remove an ovarian tumor. Nathan Smith, of Dartmouth and Yale, in 1S21, removed an ovarian tumor without knowledge of McDowell's work. Slowly the practice extended so that now, for a hundred years, ovarian surgery has been recognized and followed in this country. It was not until the development of aseptic surgery, however, that the practice became universally established. Ovariotomy is a misnomer. Prop- erly, the term should be oophorectomy,* but that word is commonly used to designate the removal of an inflamed ovary, while ovariotomy, meaning properly the cutting open of an ovary, has come to designate the removal of an ovarian tumor. No form of treatment other than extirpation serves to remove ovarian tumors. Let me say a preliminary word in regard to the re- moval of solid tumors of the ovary. The technic is extremely simple; the maneuver differs in no essential respect from that of the removal of a tumor of the tube. The surgeon opens the abdomen near the median line by a longitudi- nal incision; walls back the intestines, with the patient in the Trendelen- burg position; seeks the tumor; clamps its pedicle, or dissects out the mass if it be intraligamentous ; removes the growth, and repairs the rent in the broad ligament. All this is simple. So accomplished a surgeon as M. H. Richardson maintains that all ovarian tumors, cysts as well as solid tumors, should be removed entire in this fashion, for one cannot always foresee the nature of a cyst before it is opened. It may contain malignant elements, in which case its removal uniuptured and entire will forestall subsequent malignant involvement of other parts. I S3'mpathize entirely with this view, and recommend the total removal of ovarian tumors unruptured in most cases. Occasionalh', however, 1 Greek, ii>6v, (ptjxj. TUMORS OF THE OVARIES 339 one (encounters an ovarian tumor so enormous or so extensively ad- herent that its removal by a motlification of the classic tapping method is inevitable. That classic method is still useful. As ovari- otomy was the operation of pioneers in abdominal surgery, the subject was long involved in a voluminous and needless discussion relating to details of technic, and countless curious instruments and other matters with which early Listerism concerned itself. To-day the classic opera- tion even is simple enough, and, as John Homans used to say, its only point of interest for the surgeon lies in his endeavor to operate through the smallest possible abdominal opening. One enters the abdomen above the pubes through the rectus muscle, and at once explores the wall of the cyst, to ascertain the presence of adhesions. If the cyst is fairly free, the patient is turned on the right side, a gauze handkerchief is laid in to protect the peritoneum from dis- charges, and a Spencer Wells trocar is plunged into the cyst. Through the trocar the cyst fluid is led off by a iiibber tube into a receiving bucket. AYith the emptying of the cyst its wall collapses and the surgeon's as- sistant hastens the emptying by pressing upon the patient's flanks. Should several large cysts be present, they may be tapped severally, the sac being gradually drawn out of the wound by grasping forceps and the tap incision being closed with Nelaton's forceps. Should there be no complications, the fluid contents may thus be almost completely evacuated, after which the collapsed sac easily may be drawn outside of the abdominal wound. The surgeon then double-clamps the pedicle and dissects it between the clamps. We used to apply the compUcated Staffordshire knot to secure the pedicle. A better practice is to ligate separately the two divisions of the ovarian artery on either side of the pedicle, then to cut awaj^ the pedicle stump and repair the rent in the broad ligament. By this measure all danger of secondary hem- orrhage is eliminated, for the student should remember, as a point of interest, that in the old days slipping of the hgature and fatal hemor- rhage from the pedicle was an occasional accident. The complication of adhesions and supplementary growths must be dealt with as I have frequently before described — by dissection and separation of adhesions, by repair of torn bowel, and by removal of growths. Ovarian tumor complicating pregnancy is another serious con- dition which should be recognized early by the physician and promptly treated. The danger of this complication lies in the possibility of twisting of the pedicle, rupture of the cyst, abortion, obstruction to labor necessitating Cesarean section, or ovariotoni}- during labor. This complication, when discovered early, should be met b}' early ovar- iotomy. If the operation be simple, abortion is unlikeh', especially if liberal doses of codein or the bromids be employed at once in the after- treatment. 340 FEMALE ORGANS OF GENERATION TUBAL PREGNANCY Tubal pregnancy is one of the groat and interesting subjects of niotlern surgery. The clanger of the condition is extreme; the situation is often unexpected; and prompt, heroic treatment frequently is de- manded if life is to be saved. We were formerly wont to talk about tubal ]:)regnancy, ovarian preg- nancy, abdominal i^regnancy, but we now know that tubal pregruuicy is properly the primar}^ condition in all these cases, and that apparent development of the fetus in the ovary or free in the abdomen is secondary to primary tubal pregnancy. Extra-uterine pregnancy is a proper term, as is ectopic gestation. The cause of tubal pregnancy is now generally recognized to be a lodgment of the imjDregnated ovum somewhere in the tube. The ovum does not cling to the mucous lining of the tube, but apparently burrows into it, lodging in some crypt or fold or other abnormal formation, the consequence of a previous salpingitis. The site of lodgment gener- ally is in the ampulla of the tube, though isthmic pregnancy and in- terstitial pregnancy (within the uterine wall) are not unknown. It is needless here to discuss the formation of the chorion, amnion, decidua, and placenta further than to state that these structures develop on lines similar to the normal, except that the placenta is derived almost entirely from the embryo and not from the tubal mucosa. As the products of conception develop, the wall of the tube becomes thinner and thinncn-, and in this thinning lies the danger of the condition. The course of a tubal pregnancy runs uninterrupted usually for from three to ten weeks, but during the latter half of this period one of two accidents almost invariably occurs — tubal abortion or tubal rupture. Malcolm Storer ^ has shown that tubal abortion is a more common accident than at one time was supposed, and occurs usually about the sixth week of pregnancy, while tubal rupture occurs between the eighth and tenth weeks. Probably more than half the cases of tubal pregnancy end in tubal abortion. This phenomenon consists in the expulsion of the ovum through the open, fimbriated end of the tube, when it may become implanted upon the ovary or upon some other adjacent part. The symptoms of tubal abortion are pain of varying intensity, together with an escape of blood from the uterus. The pain is rather characteristic — brief, stabbing, not colicky, and by no means so severe as is the pain of tubal rupture. The pain and the flowing lead the patient to consult a physician. The cause of the abortion is believed to lie in the fact that the glandless tubal mucosa hypertrophies but slightly, and does not form a decidua, as is found in the uterus. The chorionic villi of the growing ovum perforate this thin layer and open into the enlarged tubal vessels, thus gi^'ing rise to a hemorrhage which separates the ovum and results in the aboi'tion.- In most cases of tuljal abortion the ovum perishes with its expulsion from the tube, but heni- 1 Boston Med. and Surg. Jour., .January 7, 1904. 2 Marshall, Lancet, March 26, 1!»04. TUBAL PREGNANCY 341 orrhage persists generally in both directions. Frequently blood is pounnl out into the abdoniinnl cavity and within the folds of the broad ligament. Pelvic hematocele, so called, then results; the patient may become alarmingly weak, and prompt operative treatment be imperative. In rare cases the ovum lodges upon the ovary, where it develops and may continue even to full term. This form of pregnancy has been called ovarian 'pregnancy, and there is still debate whether the pregnancy ever is primary in the ovary, or is always secondary to a tubal pregnancy. Again, the ovum may lodge elsewhere in the abdomen and develop, in which case we speak of the condition as abdominal 'pregnancy. Abdominal pregnancy is always secondary to tubal preg- nancy, and is the result of tubal abortion. About half the tubal pregnancies may not result in tubal abortion, but in tubal rupture, in which case immediate death of the fetus en- sues almost invariably. Tubal rupture is due to a great thinning of the tube, distended by the growing ovum, until the tube breaks, with discharge of the ovum and an accompanying profuse hemorrhage. There are secondary changes in the uterus associated with tubal pregnancy. The uterus enlarges somewhat and forms a decidua, as does the tube. If the abnormal pregnancy advances far, the uterus becomes pushed to one side, while the vagina and cervix show the char- acteristic engorgement of pregnancy. The woman's breasts become enlarged and the areolae dark. Such are the more common structural and tissue changes one sees in the case of ectopic gestation. Very little imagination is required to realize the gravity of the condition and the frightful accident which it may precipitate — an accident de- manding prompt and thoroughgoing treatment. The S3rmptoms and diagnosis of extra-uterine pregnancy may be characteristic and obvious, or the reverse. In most cases the diagnosis is not made until some catastrophe occurs. Often, at first, menstruation is somewhat disturbed — retarded or irregular; while in a large number of cases it ceases altogether. There is frequently " morn- ing sickness," and at times nagging pelvic pain with faintness. Some- times persistent flowing will come on after six or more weeks of amen- orrhea— persistent flowing, frequently mistaken for a miscarriage by the medical attendant. Or the physician may discover a tubal preg- nancy, finding a doughy mass at one side of an empty but slightly en- larged uterus. At this stage he should base his diagnosis of extra- uterine pregnancy upon the four cardinal symptoms — disturbed men- struation; sharp pelvic pain and faintness; an extra-uterine ma-ss, and an enlarged, empty uterus. When we come to the symptoms and diagnosis of surgical calamity associated with tubal pregnancy, we are in deeper waters, and it is with calamity that the surgeon is generally concerned. I have al- ready described the symptoms of tubal abortion, which are notably pain of an endurable character, but prolonged and distressing, extreme faintness, and the evidences of internal hemorrhage — rapid, thready pulse, cold extremities, blanched aspect, distended and tender abdo- 342 FEMALE ORGANS OF GENERATION men, dyspnea, and subnormal temperaturo ; or all these symptoms may be present, but in milder degree. Generally, a mass may be felt in the pelvis if the patient be not too fat or too tender for a proper physical examination. Usually, blood is seen to escape from the os uteri. Even with these signs the surgeon may be unable to determine accur- ately the nature of the accident that has occurred, but he sees that a grave abdominal emergency demanding o])eration is before him. The syniptot)is of tubal rupture are more alarming even. The most obvious phenomena are the agony and prostration of the woman. Once witnessed, the scene cannot be forgotten: the blanched, exhausted patient, moaning or screaming in agon}', writhing and involuntarily and uselessly attempting to discharge her load by frantic straining. The crisis passes in a few minutes, or may last several hours. The rending of the tube ceases. Pain becomes less, but hemorrhage does not stop at once, and a condition of almost pulseless exhaustion super- venes. We know that a great amount of blood has been poured out into the abdomen or extraperitoneally between the folds of the broad ligament. The patient may be so exsanguinated, and the heart so exhausted, that bleeding ceases spontaneously for a time, but we never know how soon the heart may revive or how soon a second and a third hemorrhage may ensue. Such are the calamities — tubal abortion and tubal rupture — com- monly resulting from extra-uterine pregnancy. A rare outcome of the condition is the expulsion into the abdomen of a living fetus which lodges, grows, develops, and reaches full term, or an age approximat- ing to full term. The fetus then dies, the placenta becomes detached and disintegrates, while the fetus, as a foreign body, may be carried for years by the mother; it may become disorganized or calcified (litho- pedion) ; it may form a focus of infection, and portions of it may penetrate the hollow viscera and be discharged through the rectum or vagina or through the abdominal wall even. Such, in extremely brief detail, is the story of extra-uterine preg- nancy, and the student will realize the grave difficulties which encouter him when he comes to consider treatment. Treatment. — In those earliest stages of which I spoke, if the pres- ence of an extra-uterine pregnancy is fairly well determined, the one and only course for the surgeon is operation. Open the abdomen and remove the enlarged tube. The operation at this stage is simple and the danger no greater than the removal of a chronically inflamed tube. I have already described the technic. In the case of the alarming symptoms associated with tubal abortion or rupture, operation is also imperative, but the moment for doing the operation is not always ob- vious. Indeed, surgeons still debate the question. A few years ago all were agreed that immediate operation was as urgent in all cases as though the patient was suffering from gunshot of the intestines. We have modified somewhat this view with time, and the mode of apply- ing that modification depends entirely upon the experience and intelli- gence of the individual surgeon. If the woman be recently collapsed, TUBAL PREGNANCY 343 if pain be still present and the pulse fair, — 120 or under, — I believe one should immediately o])en the aljdomcn and control the hemorrhage. On the other hand, if the patient be in profound shock and almost pulse- less, one knows that a severe surgical operation may turn the scale and kill the victim. What, then, shall the surgeon do? Fortunately, we have learned from much experience that most women do not die at once under these alarming conditions — that hemorrhage spontaneously ceases and that the heart rallies. I do not think it safe actively to stimulate such patients except that I sometimes give a hypodermic injection of strychnin (e'o or :jV gr.) and watch closely the result. Of all things, give no saline infusions. In any event, we usually see the patient rally slo^\ly from the condition of extreme shock. Then we know that hemorrhage has ceased temporarily, and that if we stand by, ready to operate at a moment's notice, the proper time will soon arrive. I have thus waited tw^o, three, and four hours, and am convinced that in the case of persons suffering from extreme shock waiting is often the wiser course. In other words, catch your patient on the rebound, when you may operate and save her life. I submit that there are few surgical emergencies calling for greater tact, resourcefulness, judgment, and swift technical skill. The method of the operation is simple. With the patient in the Trendelenburg position, open quickly through the rectus muscle over the affected side, sweep back the intestines, seize the uterus with double hooks, draw it into the wound, and clamp the ruptured tube at both ends. Then remove the tube in the fashion I have described, scoop out blood-clots and the products of conception, wash out quickly the ab- domen with an abundant hot saline douche, close the w^ound, and put the patient back to bed as soon as possible. There may or may not be ad- ditional shock. Give a stimulating enema of black coffee, brandy, and salt solution, and repeat the salt solution (10 ounces) every four hours for twenty-four hours; inject strychnin carefully, and elevate the foot of the bed. The great majority of these patients recover if they come off the table alive. Those patients who die perish at once as the result of an operation undertaken in extremis. It is gratifying to watch the rapid convalescence of these women and their prompt restoration to health. The treatment of extra-uterine pregnancy advanced to the rare con- dition of full term is another problem. The fetus, its placenta, and mem- branes are by that time implanted somewhere in the abdominal cavity outside of the tube, and can be removed, if at all, by abdominal section only. It is a simple matter to open the abdomen and remove the child, but the extraction of the placenta is a frightfully hazardous proceeding, on account of the inevitable hemorrhage which follows. Be it remem- bered that the loosening and removal of the placenta from the normal gravid uterus is relatively bloodless because the uterus contracts and shuts up its great vessels. On the other hand, when the placenta is attached to some non-contractile portion of the abdomen, its removal is not followed by closure of the vessels, so that excessive hemorrhage 344 FEMALE ORGAXS OF GEXEKATIO!': results. Commonly, such an C('to]jic placenta rocoivos its bloo(l-sup])ly through some portion of the uterus and adnexa, so that it -woukl appear as though control of uterine and ovarian arteries would check hemor- rhage from the placental site. Unfortunately, there is often a copious collateral blood-supply to the placenta, so that the ligation of uterine and ovarian arteries avails little. Removal of an extra-uterine fetus is, therefore, one of the most hazardous undertakings in surgery — to be attempted by the most skilful operator only, who may be obliged to compress the aorta in order to control hemorrhage. P'or this rea.son I recommend the easier and safer method of removing the child, stitching the sac into the wound, packing, and leaving the })lacenta to dislodge itself later. These children, if they survive, may be as vigorous as those born in the natural manner. PELVIC HEMATOCELE Pelvic hematocele was formerly the term applied to most collections of blood within the pelvic cavity — pelvic hematocele and hematosalpinx. We are now assured that a majority of cases of j^elvic hematocele and hematosalpinx are due to tubal pregTiancy. Such collections of blood may be within the folds of the broad ligament, as I have described, and may burrow under the peritoneum in various directions, or the blood may be free in the pelvic cavity. We formerly practised vaginal sec- tion in order to clear out such hemorrhagic collections, but of late j-ears we are convinced that the best practice is to open from above, so as quickly and sureh' to explore, to control hemorrhage, and to remove thoroughly all the products of gestation. CHAPTER XII PERINEUM AND VAGINA Surgical interest in the female perineum centers in the treatment of its childbirth lacerations. There are numerous other perineal lesions, but they are mostly simple disturbances easily treated. At the beginning of Chapter X some mention was made of the anat- oni}' of the perineum, and it is well to repeat here the statement that, by the surgeon, the perineum must constantly be regarded as a floor, ingeniously constructed to support the pelvic and abdominal organs. Damage to this floor means displacement of organs, and often a far- reaching course of ailments, such as I have already described in speak- ing of uterine displacements and other ptoses of the abdominal organs. It remains for us now to consider means of repairing damage to the per- ineum. I pointed out in Chapter X also how the structures of the perineum are divided into superficial and deep layers. It is laceration of the deep layer which calls most urgently for surgical aid. Damage to the superficial layer results in local discomfort onty. PERINEAL LACERATIONS The leading feature of deep perineal damage is laceration of the levator ani muscle — the great muscle which supports the pelvic viscera. Until recent years we failed to appreciate the significance of tears of this deep muscle, so that the old-time operations for repair of the per- ineum were directed to the reconstruction of damaged superficial parts — the skin, the fourchet, and sometimes the sphincter ani. Reynolds ^ showed, years ago, the form and character of fresh perineal lacerations and the mechanism of these lesions. As seen immediately after child- birth, the tear is somew^hat Y-shaped, crescentic in the vagina, with a single prolongation through the labia. The crescentic portion of the tear is that which penetrates deeply through the levator ani muscle; the downward prolongation divides the skin and the sphincter ani even. A result of extensive tears of this nature is a relaxation and do^^-Lward sagging of the pelvic floor, with the superimposed organs. Treatment. — A description of the popular operations for repair of the lacerated perineum would necessitate a long, complicated historic essay, suitable for a special text-book only. Let us study the simple and effective operation which I favor especially, and then mention one or two of the other better known procedures. For a more clear understanding of the purpose of perineal repair let me again remind the reader that laceration of the levator ani makes for not only uterine displacement 1 Edward Reynolds, Trans. Amer. Gyn. Soc, September, 1891. 345 346 FEMALE ORGANS OF GENERATION .2I^ 'j^^m_ ^ 1 1 1 1 1 1 7n> £ h 0. ;a ^ T-.i^, ft . _ j_i ■or Fig. 214. — Cystocele and rectocele. Fig. 215. — Flap-splitting operation for repair of perineum — step 1 (redrawn after Aitken). PERINEAL LACERATIONS 347 and descent, but also for sagging forward of the anterior rectal wall (reckx'cle), and sagging backward and downward of the bladder (cys- toc'cle). The operation which 1 shall now describe remedies in great measure both rectocele and cystocele. By the following operation we aim primarily to seek out and stitch together the ruptured fibers of the levator ani; to this end, split the septum between the vagina and rectum through a crescentic incision drawn around the lower border of the vagina or just within the vagina. The lateral portions of this cut enter readily through the skin and super- ficial fascia, and open the ischiorectal fossa. So far there is no diffi- Fig. 216. — Repair of perineum — step 2 (redrawn after Aitken). culty, but the separation in the median line, between the vagina and rectum, often demands a painstaking and laborious dissection through a great amount of tough scar tissue.^ By keeping close to the vaginal flap, however, one may avoid opening the rectum^an awkward com- plication. When the scar tissue has been dissected through, the vagina and rectum peel apart readily, and then quickly with the fingers one deepens the wound if needful up to the uterine cervix. There is not the 1 Tliis operation is in many respects that practised by Lawson Tait twenty-five years ago, and still described as Tait's operation in many of the text-books. I recog- nize it as Tait's operation, but on carefully reviewing liis description cannot find that he carried his dissection as deep as I feel generally to be advisable. 348 FEMALE OUGAXS OF GENERATION' slightest danger of entering the peritoneal cavity. Often there is trou- blesome bleeding from large hemorrhoidal veins, which should be care- fully secured as one progresses. The whole wound should be made as dry as possible, though the checking of all oozing is not easy. ^^'ith the depth of the wound now exposed and the sides held widely apart with retractors, one sees or palpates readily the strong edges of the divided levator ani muscle. The rest of the o])eration consists in placing the stitches properly and securely. For this the operator must Fig. 217. — Repair of perineum — step 3 (redrawn after Aitken). now sacrifice his left forefinger by introducing it into the rectum to act as a guide for the needle. Three or four heavy, deep, absorbable, buried catgut stitches are enough to unite the edges of the torn muscle. One may use the kangaroo tendon, chromicized catgut, or the catgut prepared by Bartlett's method, which I prefer. The torn edges of the levator ani muscle can be most effectively approximated b}- inserting figure-of-8 stitches. Having tied these deep stitches, a second row of lighter buried stitches is passed to bring together the more superficial no H IN 10 A I. LACERATIONS 349 parts. If the sphincter aiii Ik; torn, the lowermost of these stitches may- be piissctl deeply throiineral terms nuich the same situation arises as we saw in the case of ruptured kidney. There are the primary shock, pain, and hemor- rhage, varying in extent, but generally less conspicuous than with rup- tured kidney. If the penetrating wound be extensive, the kidney may prolapse through it. The ureter is rarely injured, but the danger of infection is great. The symptoms are quite similar to those of ruptured kidney, and the treatment is analogous. It may seem wise at first simply to clean the wound and await developments. Later, if pain, hemor- rhage, and collapse continue, and if sepsis supervene, one should cut down upon the organ and treat it by suture, tampon, or excision, as may seem wise at the time. Open wounds of the kidney are rare as compared with subcutaneous wounds. STONE IN THE KIDNEY Stone in the kidney (nephrolithiasis; calculus), more than any other form of renal disease probably, concerns the surgeon. In study- ing the formation of gall-stones (Chapter V) we saw that they are de- pendent upon a primary infection — first, the infection; then, the in- flammation; then, the formation of biliary concretions. The formation of renal concretions appears to follow a reverse order, so far as our studies have instructed us. Urinary concretions form commonly in the kidneys and in the urinary bladder, though they may be found anywhere in the urinary tract, but their deposition seems to be dependent upon a condition of the excreted urine itself, rather than upon any inflam- matory condition of the renal or bladder mucosa. There are exceptions to this rule, as is seen in the formation of urinary concretions secondary to obstruction and inflammation somewhere in the urinary tract. The right kidney, like other structures on the right side of the abdomen, is the more frequently the seat of stone, though rarely both kidneys may bear calculi. As a rule, however, nephrolithiasis seems to be a part of a general condition. The older writers included it under the term " gouty diathesis." All the old writers talk of stone, and from the beginnings of surgery the treatment of stone has exercised general practitioners .and specialists. For a deposit of these concretions an excess of certain of the solid constituents of the urine seems to be necessary. So long ago as 1776 Scheele discovered that uric acid was a normal constitu- ent of the urine, and that many calculi were made up of uric-acid crystals. Since then we have learned that other salts may enter into the formation of stones — calcium carbonate, calcium phosphate, calcium oxalate, and the corresponding salts of magnesium and ammonium; more rarely cystin and xanthin, and very exceptionally indigo. As a rule, the calculi contain a mixture of these substances, especially of uric acid, but as one or the other predominates, they are known as uric acid, oxalate, or phosphatic calculi, etc. The extremely finely divided deposits found in the kidney substances of infants are knoT\n as infarcts, and are found in the renal parenchyma; but calculi of any appreciable 24 370 GENITO-URINARY ORGANS size are deposited in the larger spaces, in that portion of the urinary apparatus which, beginning with the papilla>, inckides the renal calices, the pelvis of the kidney, the ureter, and the bladder. Renal calculi are found in persons of all ages, though such calculi are not connnon before puberty, and males are affected more commonly than are females. Not only are stones found independently in the passages, but they are frequently seen associated with such crippling diseases as tuberculosis, tumors, and any lesion which causes obstruction to proper urinary drainage. The stones vary in size from microscopic crystals to masses as large as a pullet's egg or larger. In the order of freciuency one finds uric-acid calculi, oxalate calculi, phosphatic calculi, calcium carbonate calculi, and cystin calculi. The last two are rare, and rarer still are the xanthin and indigo calculi. The symptoms of urinary calculi are obscure and variable. I have many times suspected calculi when they did not exist, and in comn;on with all surgeons I have cut down upon the kidney and ureter only to find that they were free from stones. Diverse diseases simulate renal calculus — appendicitis, biliary calculus, floating kidnej-, renal tuVjer- culosis, renal tumor, spinal caries, sacro-iliac disease, and other more rare ailments. There are four cardinal symptoms of renal calculus: (1) Lumbar pain; (2) hematuria; (3) anuria; (4) pain on micturition. One or all of these symptoms may be absent. An aseptic calculus, which lies quietly within the renal parenchyma or even in the renal pelvis, may cause no pain ; but if infected and motile, it may cause ex- cruciating pain, especially in its attempts to pass out of the pelvis into the ureter. There is a characteristic pain of renal calculus: pain beginning in the lumbar region and radiating toward the scrotum, extending even to the thighs, the. buttocks, and the abdominal organs. The pain may be sudden and acute, or it may be of gradual onset and long continued. The agony of this pain will break down the sternest philosophy. The strong man trembles, sweats, groans, and collapses. There may be nausea and vomiting ; there may be intense vesical tenes- mus, with the straining out of a few bloody drops. If there be a mere slight passage of gravel through the ureter, all these symptoms may be present, but in milder form ; and all these symptoms may not be due to the passage of a renal calculus. Renal calculus is a common cause, but any cause which produces an increased tension of the renal capsule may provoke the same symptoms. Hemorrhage may be micro- scopic in amount, or may be so profuse as to endanger life; the amount usually is small. Hemorrhage alone is not pathognomonic. It is found under other conditions, such as tuberculosis and tumor. In the case of calculus, it is part of a symptom-complex. Anuria is usually a grave symptom. The case is bad enough when a calculus completely blocks one ureter, but it is much more serious when, through reflex irritation, urine fails to flow from either kidney. Total anuria is well recognized, but is rai-e. Renal calculus may cause bladder irritation, with urgency and frequency of micturition and pain in the urethra at the close of the act. STONE IN THE KIDNP]Y 371 Such arc the leading symptoms of renal calculus, and on these symptoms one attempts to found a diagnosis. Pain and hemorrhage are of the first consequence. Sometimes one can feel an enlarged kidney, cystic from ureteral obstruction. Rarely one can feel a calculus in the ureter, either b}' abdominal palpation or by palpation through vagina or rectum. Some writers assert that strong percussion in the loin pro- duces characteristic pain when calculus is present in the kidney. I have not found this to be true, though any manipulation in that region is often resented by the sensitive kidney. Intermittent hydronephrosis sometimes is present, due to the alternating impaction and retreat of a stone from the ureteral stoma. Analysis of the urine sometimes is of value. It is of value in the case of a movable and infected cal- culus, causing hemorrhage and inflammation. So we expect to find blood and pus. The condition of the urine varies; tRerefore numerous examinations should be made: sometimes there will be found a few casts and crystals of varying character. The cystoscope reveals alterations in the flow of urine from the ureter of the affected side — bloody urine, cloudy urine, or an actual suppression of urine. The x-tslj reveals renal calculus often, but the density of a;-ray shadow^s varies with the nature of the calculus, A calculus of oxalate throws a strong shadow, easily demonstrable^ as a rule; but uric-acid calculi or calculi com- posed of urates throw" such indistinct shadows that these shadows can- not always be recognized as a basis for diagnosis. One reason for the obscurity of these shadows lies in the fact that the kidney is not an immovable organ. Phosphatic calculi throw almost no shadow. We are coming to see that x-ray investigations for urinary calculi must be in- trusted to the most experienced experts only. Finally, renal or ureteral calculi may be demonstrated by the wax-tipped ureteral catheter. H. A. Kelly was the first to employ such a catheter. The smooth surface of the wax is found to be scratched by the stone after the catheter has explored the ureter. Thus we have seen the difficulties which encumber a diagnosis of renal calculus, and lend an element of uncertainty to treatment. The treatment of renal calculus cannot be discussed casually, yet a satisfactory discussion of treatment is a long story. Every case has its own proper indications for treatment, or perhaps its lack of indica- tions, since we are often uncertain in our diagnosis. Treatment is directed to three ends: to remove calculi, to repair damage caused by the calculi, and to provide against the recurrence of calculus. If a calculus be present, operation must be our resort.^ The much-vaunted solvents of stone are of no value when once the stone is formed, though in order to bring the patient into good condition, systemic treatment is useful before operation, and must be continued after operation: a limited diet; little or no meat; the consumption of cereals, vegetables, and milk; abundant water-drinking, and iron for a long time.^ The ' Urinary sand may sometimes be removed by the free use of diuretics and the drinking of piperazin water or lycetol (10 grains in water four times daily). - Five grains of Blaud's pill before meals. 372 GENITO-URIXAKV ORGANS patient should exercise regularly between attacks, and strive In every way to ])uild uj) his i)hysical condition, especially re^ulatiii^j; the ])o\vels by such appropriate laxatives as Carlsbad salts and cascara sagrada. Thirty years ago surgeons were beginning to operate for renal cal- culus, and the teaching in those days prescribed removal of the kidney as the only resort. Experience has taught that this is by no means al- ways necessary, and we now preferably remove the stone, either by splitting through the parenchyma of the kidney, or, better, by oi)ening the renal pelvis or ureters. Schede, quot- ing Israel, enumerates 5 indications for oi:»eration: (1) Calculus anuria, either uni- lateral or bilateral; (2) an acute su])])ura- tive process induced by calculus; (3) ob- struction of a ureter by calculus ; (4) severe renal hemorrhage; (5) intense pain or con- stant, long-continued, dull pain. "Writers still debate whether or not it is proper to operate at once upon making the diagnosis, or to delay and employ palliative measures. I suppose the answer to this question must always remain doubtful, and nuist depend somewhat upon the circumstances and temperament of the patient. On the one hand, one would hesitate to operate, even with an assurance of finding stone, upon an old person with seriously damaged kidne3-s. On the other hand, one wovdd operate at once upon a vigorous young person one of whose kidneys contained an aseptic calculus. My own habit is to operate always and early when a reason- ably positive diagnosis has been made, provided the usual tests show that one of the kidneys is doing its work properly, and provided the patient is not suffering from any other serious organic lesion. The best way to reach the kidney ^ is through the lateral oblique incision, which I have already described in this chapter, turning back the peritoneum, and giving a liberal exposure to the renal and uretei-al regions. The kidney is then dislocated and brought well up into the wound. It has been suggested that if calculi are not readily palpated, they may be seen with the fluoroscope, but I cannot regard this test as essential, nor do I recommend it, because absence of the expected shadow does not necessarily mean absence of a uric-acid or phosphatic stone. With the kidney in hand, three methods of exploring it for stone have been in common use — needling, opening the pelvis, and splitting the ^ For various methods of exposing tlie kidney I refer the reader to John F. Binnie's Manual of Operative Surgerj', part iv, Chapter I. Fig. 233.— A, A, " Brodel's white Hne"; B, B, line of best incision for splitting the kidney (Campbell). STONE IN THE KIDNEY 373 parenchyma (noplirotoniy). Needling has fallen into disuse, as it is uncertain. Surgical ()})inion is divided on the question of approach through the p<'lvis or through the parenchyma. Approach through the pelvis is gaining in popularity, and I personally prefer to employ it. It is extremely easy: the surgeon seizes the kidney in his hand; incises the pelvis ; searches the pelvis and calicos for stone ; and repairs the rent with Lembert stitches. The wound must be drained, for it often leaks urine for several weeks. A splitting of the parenchyma was and still is a popular method with many surgeons. At first thought one might suppose that it would give rise to uncontrollable hemorrhage, but the studies of Zondek and Brodel have shown that by splitting longitudin- ally in a line from 0.5 to 0.7 cm. (0.2 to 0.3 inch) behind the middle line, one will avoid wounding important vessels. The boundary line be- tween the arterial system of the anterior and posterior portions of the kidney is sharply distinct. Split the cortex, then, and open one of the calices. Splitting the kidney substance results in a considerable hemorrhage, which is sometimes alarming, but this may readily be checked by pack- ing. Some surgeons control hemorrhage by placing a temporary rubber ligature about the renal vessels and removing it at the end of the opera- tion. When one of the calices has been opened, it may be searched with an instrument or the finger, and through this opening the exploration may be continued into the other calices and the renal pelvis. In this way an exhaustive search readily is made, so that there is no excuse for overlooking the smallest calculus. Thus the sur- geon may remove stones and may wash out and drain the renal pelvis. At the end of the opera- tion he had best treat the kidney by gauze packing, securing it, if he so choose, by one or two light catgut stitches, which are soon absorbed. The parietal wound Fig. 234. — Ureteral stones (actual size), should not be closed tightly, but which caused excessive pain and were ,,■,.• V ij passed by patient per urethram. gauze or tubal dramage should ^ -^ ^ ^ be employed for two or three days. There is a leakage of urine through the fistula for a time, but if the operation has been done thoroughly, the fistula closes promptly. I have described the most useful and generally applicable methods of dealing with these stones by operation. Rarely it may seem best to remove the kidney — when the parenchyma is in great part destroyed, when extensive suppuration is present, and when a restoration of func- tion, wdthout the subsequent formation of stones, seems improbable. A small stone causing agonizing pain may be lodged in the ureter, in which case that canal must be explored and the stone removed. Stone 374 GENITO-URIXARY ORGAN'S high in the ureter is reached by the latenil incision and by splitting longitudinally the ureteral tube. Sometimes stone low in the ureter is approached through the vagina or through the bladder, opened above the pubes. Sometimes a ureteral stone may bo pushed up into the renal pelvis and reUiovcd from this point, when the kidney has been opened for stone; or it may be possible to squeeze a ureteral calculus down into the bladder. J. H. Gibbon prefers the easy and simple approach to the ureter by the transperitoneal route through a short incision, such as is usually made to find the vermiform a{)pendix. If one has opened the ureter, it may be closed satisfactorily with fine silk Lembert stitches. The surgeon nuist drain a sutured ureter through the external wound. HYDRONEPHROSIS Hydronephrosis is a dilatation with aseptic urine of the renal pelvis, but if infection take > place, the contained fluid becomes purulent, and the process may go on to involvement of the renal parenchyma. True hydronephrosis is due to a mechanical obstruction to the escape of urine from the ureter — congenital or acquired obstruction. Congenital obstacles are rare, such as imperforate ureter or ureter obstructed by an anomalous branch of the renal artery. The acquired obstacles are more common, and perhaps the most common of such obstacles is kinking of the ureter, due to prolapse of a movable kidney. Again, the ureter may be obstructed anywhere in its course by the pressure of tumors, by diseases and injuries of its own wall, by a calculus or foreign body, by inflammatory exudate within the bony pelvis, by disease or tumor of the bladder, or by operative ligation of the ureter (J. Del- linger Barney). Such obstructions may lead to a great accumulation of fluid not only within the renal pelvis, but within the kidney itself, through great dilatation of the calices, pouch formations, and stretching and thinning of the parenchyma and capsule. The hydronephrotic tumor may reach a great size — as large as a child's head even. False hydronephrosis is a collection of fluid on the outside of the kidney. The symptoms of hydronephrosis are gradual and vague in their onset, though one form, intermittent hyrlronephrosis, so called, due to the ureteral kinking of movable kidney, is characterized by recurring at- tacks of pain, the formation of a tumor, and subsidence of the swelling, with a sudden abundant discharge of urine into the bladder. Commonly, however, hydronephrosis is associated with dull pain in the loin and with a diminution of the urine passed. There is no fever; gradually a pal- pable tumor reveals itself. Sometimes there is an associated histor\' suggesting renal calculus or the symptoms of malignant disease, with its characteristic pain and cachexia. We establish the diagnosis of hydronephrosis by observing such symptoms and feeling a fluctuating cyst. The treatment of hydronephrosis must be operative. When ad- vanced coincident disease is present, such as cancer of some other organ, PYELITIS 375 one should attempt nothing more than permanent drainage of the renal cyst, in order to reli(^ve pressure and discomfort. Should the patient's condition admit, adventitious tumors are removed. Disease and injury of the ureter itself arc to be treated by exposing the ureter and excising the damaged portion. In many cases one may then per- form ureteral closure cither by end-to-end suture or by implanting the upper into the lower portion, after the method of van Hook. Obviously, an impacted calculus, an obstructing blood-clot, or the rare ureteral neoplasm must be removed, and crippling pelvic exuda- tion must be appropriately treated. Hydronephrosis, due to kinking of the ureter, commonly associated with movable kidney, sometimes with an abnormal branch of the renal artery, and inter- mittent symptoms, is an espe- cially interesting condition, because its proper treatment restores completely the func- tion of the kidney at the same time that it cures the disease. As long ago as 1S92 Fenger, of Chicago, treated successfully this ureteral kinking by an operative pro- cedure similar to the fam- ous Heineke-Mikulicz pyloro- plasty. We now apply this principle to stricture of the ureter. At the same time, if the kidney is movable, we fix it. Some surgeons have provided a free drainage to the renal pelvis by making an anastomosis between the pelvis and the ureter, while others have resected large portions of the wall of the sac. The literature of this subject is extensive, and the numerous operations proposed are ex- tremely ingenious. PYELITIS Pyelitis, pyelonephritis, and suppurative nephritis are conditions distinctly susceptible of surgical treatment. Infections of the kidney and its pelvis come about through the blood-stream or by direct ex- tension from below" — from the bladder and genitals up through the ureter. We were formerly taught that all renal suppuration came from below, but it is now apparent that this is not the case; and when one Fig. 2.35. — Van Hook's method of lateral implantation of the ureter: A, The renal por- tion of the ureter split longitudinally, the ends trimmed so as to admit of easy implantation, and the loop of catgut passed; B, showing the method of passing the needles so as to draw the renal portion into the vesical portion; C, the im- plantation completed (Fowler). 376 GEXnO-lIlIXARY ORGANS considers the excretory function of the kidney, one perceives how in- evitably it is subject to damage in connection with all sorts of diseases. Pathogenic bacteria lodge in the kidney in the course of measles, small- pox, scarlet fever, typhoid fever, and tuberculosis; while the colon bacil- lus and pus-producing cocci all may pass through it. Gonorrhea, as. well as infections from parturition, are common causes of renal sup- puration. A familiar old term for these renal inflammations is " surgical kidney." We need not consider here the suppuration due Fig. 236. — Surgical kidney (Warren Museum, Harvard). to tuberculosis and calculi — the commonest of all forms of renal sup- puration. The progress of surgical kidney may be acute or it may be chronic. The disease may be limited to the renal pelvis, or the whole organ may be invaded and rapidly destroyed. The kidney becomes enlarged and softened. Blood is extravasated, so that one observes the general appearance of an embolic infarct. The infected tissue breaks down, and numerous small abscesses are formed throughout the kidney; or there may be affusion of many small abscesses into a few great pus- pockets, so that the kidney is changed into a network of degenerated parenchyma, partly separating the abscess cavities. Then the fatty PYELITIS 377 capsule shrinks; the kidney may become adherent to surrounding tissues; pus nuiy break out through the capsule, or paranephritic in- fection may occur; so the process may be unlimited or limited to the pelvis or to the kidney proper or to both; while the symptoms of the condition and its gravity must depend on the virulence of the infection and the extent of the inflammatory reaction. The symptoms of surgical kidney are extremely variable, and the diagnosis may be correspondingly difficult. A suppurative nephritis of embolic origin is accompanied by sharp attacks of renal colic, suggest- ing stone, and, indeed, a calculus may be present. After such an attack one finds great quantities of bacteria in the urine. Again, with an in- fection of gradual onset there is a dull ache merely in the loin, and a feeling of pressure. Or the case may drag on for years without any pain whatever. Usually there is an intermittent fever, which may iiin high and be associated with chills; there is almost always marked im- pairment of the general health. There may be anuria or an intermit- tent pyuria, in which latter case one may assume that one of the kidneys is unaffected, for between attacks, or during the temporary occlusion of one ureter, the urine passed from the bladder may be perfectly nor- mal. There is almost always an enlargement of the affected kidney and marked tenderness in the loin, though, rarely, these symptoms are absent. As a usual thing, however, the picture is fairly character- istic and the diagnosis not difficult. With fever, pain or aching in the loin, pus in the urine, and a tumor present, one makes a diagnosis of surgical kidney. Cystitis must be ruled out, and one may settle the question of cystitis by the microscopic examination of the urine, which shows characteristic renal, pelvic, or bladder cells, depending on the source of the irritation. One observes also the absence or presence of frequency and vesical tenesmus. An acute pyonephrosis gives a classic group of symptoms: sudden, temporary obstruction to the urine, with rapid formation of a painful, tender tumor; then a clearing up of the urine, which previously contained pus, the patient meanwhile growing worse. Sometimes, as a supplementary study, a cystoscopic examina- tion of the bladder, with segregation of the two urines, may be employed, though this is by no means always necessary. There is nearly always a leukocytosis, ranging from 15,000 upward. The initial symptoms of these renal infections in recent years have become the subject of special studies. Through these studies we have been brought to see that many of these cases formerly known as surgical kidney develop from a primary renal focus, which should be attacked early. Acute unilateral septic infarcts of the kidney is the term now used to express the condition I have referred to in this paragraph as a suppurative nephritis of embolic origin.^ The infection may be mechanical, by actual infected tissue carried to the kidney, or emboli of bacteria themselves may be lodged in the kidney parenchyma. Women are more commonly affected ^ See an excellent resume of this whole subject by Farrar Cobb, Acute Hema- togenous Infection of One Kidney in Persons Apparently Well, Ann. Surg., November, 1908. 378 GENITO-URINARY ORGANS than men. The infection may be extremely rapid and fatal, or, after a rapid onset, the symptoms may subside and the course become chronic. The symptoms of acute unilateral hematogenous infection are perplexing often. I have seen patients operated upon for diseases of the bile-passages and of the stomach, when the actual trouble was an acutel)'' septic right kidney. One characteristic point in differential diagnosis is the extreme tenderness to palpation elicited high in the costovertebral angle, when the kidney is affected. On the other hand, there may be little ])ain, and the urine may show little disturbance, though most commonly it contains blood. With such an onset as this the disease, if not quickly fatal, runs on into that course which I have described under the old-fashioned caption " surgical kidney." The acute unilateral cases are alarming and fatal often. Usually the sur- geon must operate without hesitation and remove the infected kidney if he is to save the life of the patient. Treatment of Surgical Kidney. — Recently I saw in consultation a young woman who had contracted gonorrhea five months previously, in the sixth month of a pregnancy. She was delivered safely about three weeks before I saw her. She appeared to do well for a week after her labor, when she had a chill, followed by a hectic fever, dull pain in both loins, and the intermittent appearance of pus in the urine; there was no frequency or tenesmus; the microscope showed no evidence of bladder inflammation. Both kidneys were palpable and were tender to pressure. The patient lay languid and helpless in bed, with a dull headache, furred tongue, and a feeling of great prostration. I directed the application of hot poultices over the loins, a milk diet, the copious drinking of spring water, permanent drainage of the bladder by an in- lying catheter, daily bladder irrigation, and a strychnin and iron tonic. Within a week the patient was convalescent. In the care of acute pyelitis, especially bilateral pyelitis, such treatment often will suffice. Thus the renal engorgement is dimin- ished, copious excretion of urine is secured, constant drainage with- out backing up in the bladder is accomplished, and the patient's general tone is maintained. Writers have recommended catheteriza- tion of the ureters and washing out with boric acid of the renal pelvis in such cases. Though such pelvic irrigation often is effective, I regard it as hazardous, and not frequently or lightly to be undertaken. In that case of mine the recent spread of the infection and the fact that it had attacked both kidneys rendered an extensive operation inad- visable, unless as a last and desperate remedy. Many cases of pyelitis and surgical kidney, however, must be treated by operation — when the disease is long established and fails to yield to other treatment, or when the infection is so acute and overwhelming that nothing save immediate renal drainage or extirpation of the kidney offers a chance of cure. Nephrotomy and nephrectomy are the commonly employed operations in cases of chronic surgical kidney. Nephi'ec- tomy, so urgently demanded in cases of acute hematogenous infections, seldom is necessary, and should be performed in case of most extensive PYELITIS 379 damage only in the cases of chronic surgical kidney. When this late nephrectomy is performed, the surgeon should remove the ureter at the same time, in order to anticipate empyema of the ureter; or he should stitch the proximal ureteral orifice, for drainage, into the external wound. But nephrotomy is the operation of choice. One performs it in the manner I described when treating of renal calculus. Split the parenchyma; open the calicos; explore; wa.sh out and drain all abscesses as well as the renal pelvis; control hemorrhage during the operation by a temporary ligature about the vessels of the hilus ; and, finally, treat the kidney by tampon and external drainage. In the case of extensive suppuration, it is sometimes well to stitch the two halves of the split kidney separately into the external wound, and then to pack the kidney wound. The surgeon must realize that the dangers of nephrectomy do not lie so much in the operation itself, as in the condition resulting — the patient is left with one kidney only. After all these operations con- valescence is slow and the outlook grave, for a time. One depends upon the sound kidney to do extra work; but gradually, if all goes well, the crippled kidney itself takes up its functions and a restoration to health may be anticipatedifi' For weeks a fistula in the loin of operation per- sists, however, through which urine is discharged, necessitating abundant and frequent dressings. Meantime active general treatment must be pursued and the best of hygiene secured, if possible. Paranephritic abscess must not be confounded with surgical kid- ney. It may be a sequel and direct result of surgical kidney; or it may arise from extraneous causes and run its course, leaving the kidney proper uninvolved. Such a paranephritic abscess a,s follows surgical kidney I have already described. That is the last and one of the most alarming complications of renal suppuration, and, as I have suggested, must be met by vigorous treatment involving often nephrectomy and free drainage. The more common forms of paranephritic abscesses do not originate in the kidney, but are concerned with the tissues about that organ — the fat, the muscles, and possibly the peritoneum and abdominal organs. Paranephritic abscess may break into and discharge through one of the hollow viscera, or may make its way into the pleural cavity, the lungs, and bronchi. One observes at once, therefore, that the commoner cases of paranephritic abscess are associated with little evidence of kidney disturbance. There is no pus in the urine, and such urinary changes as appear indicate nothing more than acute renal con- gestion. In other words, we have to deal with a lumbar abscess. We find the usual signs of abscess, pain, heat, redness, swelling, and fever. The only proper treatment is free drainage. With this, usually, the inflammation subsides and little more is necessary for the treatment of complications even. Fistulse gradually close and the patient re- turns to a normal condition. In the after-treatment I sometimes em- ploy large, hot creolin poultices, applied every three hours, but generally a dry gauze dressing suffices. I have found prolonged immersion of the patient in a hot-water bath to be a great comfort to him sometimes, when the inflammation was subsiding slowly, and an irritating open 380 GENITO-URINARY ORGANS wound persisted for a long time. If such bath treatment comforts and rehcves the sufferer, one may feel confident that a cure is being hast- ened. TUBERCULOSIS OF THE KIDNEY Let us consider briefly this most common and most interesting form of renal infection. Primary tuberculosis of the kidney is probably rare. The infecting organisms generally reach the kidney through the blood-stream, being taken up from foci in the chest, the abdomen, or elsewhere. It was not long ago that we believed all renal tuberculosis to be an ascending process from the bladder and genital organs, but Fig. 2.37.— Tuberculous kidney (Warren Museum, Harvard). there is now abundant evidence that this source of infection is not so common as that through the blood-stream. Infection through the blood- stream shows itself usually in one kidney, rarely in both. Infection through the genital tract seizes upon both kidneys. Fortunately for patients and surgeons, the blood-stream source is the commoner, and unilateral renal tuberculosis is more frequent than bilateral tuber- culosis. The disease is insidious usually, though it may develop rapidly in the course of a general tuberculosis. The pathologic process is similar to tuberculosis elsewhere. Small foci appear in the paren- TUBERCULOSIS OF THE KIDNEY 381 chyma of the organ; they spread, caseate, break down, and run to- gether. Frecjuently a mixed infection supervenes; abscesses form, the parcnch^-ma of the organ is destroyed; the morbid process gives rise to a considerable tumor, and sometimes extensive adhesions develop ; frequently calculi are deposited, and the ureter is invaded by tubercu- lous invasion. That involvement of the ureter is an important fact. The tube becomes thickened, narrow, inelastic, and extensively adherent. Total occlusion may take place, with a resulting coincident pyonephro- sis and distention of the ureter itself. The kidney is thrown out of action, though long before this situation is reached it may have been functionless. Such is a picture of advanced renal tuberculosis. This stage may be attained in a few months, or the disease may run on for years, chang- ing little in its pathologic aspects. It must be obvious to the reader who has made himself familiar w'ith the curiosities and amenities of pathology — it must be obvious to such a reader that the symptoms of renal tuberculosis will probably keep pace with the morbid changes, while, at the same time, a diagnosis may be extremely difficult, or may be instantly apparent. I protest that an early diagnosis is imperative, for M'e can often cure the cases taken early. We look for characteristic constitutional symptoms: emaciation, cachexia, hectic fever, sweating, rapid pulse, furred tongue, distaste for food, and anemia. Generall}', there is bladder irritation, with tenesmus and frequency. The urine may be clear, or may be loaded with pus, and sometimes with blood. One is often disappointed in the physical examination of such patients. One expects to see a pallid, emaciated victim, but such appearances come late. I have found renal tuberculosis in plump, active, red-cheeked girls, in whom the disease had not been suspected. Often one finds a tumor in the loin, enlarged glands in the axilla, groin, or neck, and perhaps scars on the bod}-. In the case of a woman one may feel by vagina an enlarged, cord-like ureter on one side, passing in front of the cervix. Some- times in thin persons of either sex the thickened ureter may be felt through the abdominal wall. Examine the urine. Look for tubercle bacilli in the sediment. As a confirmatory test inject some of the urin- ary sediment into a guinea-pig. It takes from three to four weeks for tuberculosis to develop in the animal. Examination with the cysto- scope is informing, and one maj' thus determine the source of the pus, whether from right or left ureter or from the bladder. That deter- mination of right or left is vital. The most experienced surgeon may be misled by sj-mptoms alone, and may pronounce a left kidney tuberculous when the right is at fault. Thus we make the diagnosis, observing especially pain, tumor, pus, and blood, and taking into account the hectic fever and the nature of the urinar}^ sediment. And we must remember that calculi may be present to befog us, while surgical kidney has many factors in common with tuberculous kidney. 382 GENITO-UKINAUY OllGANS The treatment of renal tuberculosis still agitates surgeons, though many are coming into some manner of accord. Not long ago we thouglit the disease could be checked or cured by an out-of-door life. Doubtless this is often true, but it is impossible to secure such a life for the ma- jority of patients. Many cannot find it, and many will not follow it. The surgeon must prescribe carefully the mode of life and proper hygiene, nutritious, fattening foods and iron for every patient, whether or not an operation be undertaken. Now, that question of operating is no longer the extremely doubtful question that it was a few years ago. Most tuberculous kidneys must be operated upon, and the sooner the better. The probability of cure or arrest of the disease iriifiout operation is not nearly so great as in the cases of pulmonary or joint tuberculosis. As a rule, removal of the kidney is the operation of choice, for thus alone, in most cases, can we assure ourselves that the whole disease has been extirpated. If the kidney is small, it is well to follow Kelly's method and approach the organ through the posterior lumbar triangle; or one may operate by the lateral flank incision. Examine carefully the ureter and remove it also. Partial nephrectomy occasionally produces a cure, but in order to excise satisfactorily a portion of the kidney one must be sure that the tuberculosis is limited to one pole, and this can be ascertained only by a searching nephrotomy — a splitting the kidney from end to end, and making sure that unsus- pected foci do not lurk somewhere in the organ. In the case of advanced disease, when the kidney is greatly enlarged, it may be difficult or im- possible to remove it at once, entire. In such a case one may empty the sac by nephrotomy, and then, at a second sitting, extirpate the diminished organ. Always in such cases one must detach with care the upper pole, on account of possible adhesions to the vena cava and the duodenum. In all cases one should be sure of the condition of the opposite kidney — whether or not it be present, free from disease, and functionating. The removal of one kidney when its fellow is tuber- culous is extremely hazardous and is commonly useless. Tuberculosis of the bladder, however, is not necessarily a contraindication to neph- rectomy. Always remove the diseased ureter. The results of these radical operations for tuberculous kidney are often extremely satisfactory. When the disease is seen earl}- and is limited, the patient may recover perfectly through the operation. TUMORS OF THE KIDNEY AND SUPRARENAL GLAND Hypernephroma is the most interesting of kidne}' new-groAvths. Although P. Grawitz described and named hypernephroma so long ago as 1883, within recent years only has the profession at large recognized the significance of the disease. Every surgeon of experience can re- member operating upon malignant tumor (sarcoma) of bone in cases in which renal symptoms and kidney tumor subsequently have appeared. Strangely enough, the association between these tumors of bone and tumors of the kidney for long went unrecognized. Indeed, only last TUMORS OF THE KIDNEY AND SUPRARENAL GLAND 383 year I saw the specimen of a sarcoma of the clavicle removed by a sur- geon who had failed to investigate the condition of the kidneys. After the excision of the bone tumor he discovered a considerably enlarged Fig. 238. — Plypernephroma. right kidney. So we see that bone metastasis is one of the significant features of hypernephroma. Grawitz gave the name to the disease. Frequently at postmortem, on stripping back a kidney capsule, one finds beneath the capsule small, fat-like bodies, the size of a pea or less. Grawitz pointed out that 384 GENITO-URINAUY ORGANS these are inclusions, — portions of the suprarenal gland, — that they may remain indefinitely -without causing damage, or that at any time during life they may take on growth and develop into consideraljle tumors — sometimes benign, sometimes malignant. These tumors are histologic- ally characteristic, showing a delicate vascular stroma, within the meshes of which are strings or groups of polygonal cells, whose bodies contain few or many fat-drops; in their stnicture and in the character of their cells these nodules resemble closely the nodules which develop in the suprarenal gland. One never can tell at what moment hyperne]:)hroma may bring forth metastases. If the growth remain localized, one may regard it as benign. If it spread so as to involve other organs, — es- pecially if growths of similar structure appear in distant bones, — it has become malignant, — one of the most malignant forms of tumor. Ob- viovisly, therefore, as soon as hypernephroma is discovered in the kidney, the whole organ should be extirpated. The symptoms of hypernephroma are no more characteristic than are the symptoms of other renal diseases, but the following i-henomena are fairly constant:^ recurring attacks of hemorrhage associated with frequency of urination, often associated with clots which, in their journey through the ureter, stop the stream (for hours or days, as shown by diminishing amount of urine), and cause fairly severe pain. Between the hemorrhages are periods not characterized by '' frequency," but by a diminished amount of urine and urea, and marked pain in the back, which persists until it disappears coinciclentally with the onset of fresh hemorrhage. These alternations of pain and hemorrhage are quite different from the symptoms of renal calculus. The urine generally shows nothing characteristic when submitted to the usual tests. The further symptoms for which one looks are those common to ad- vancing tumor-formation — pain, cachexia, and metastasis. The phy- sical examination reveals a kidney but little enlarged at times, though frequently the organ reaches a great size. The general kidney outline is retained, and usually the surface is nodular. The diagnosis is sug- gested by the hemorrhages, alternating pain, and a tliminished urea; by finding a tumor, and by the discovery of malignant disease of bone. The treatment of hypernephroma is immediate nephrectomy, wdth a prognosis always doubtful. Some patients have survived in health many years after the operation; some quickly have fallen vic- tims to metastasis. Sarcoma of the kidney often can scarcely be distinguished from hypernephroma — indeed, all tumors of the kidney, whether benign or malignant, closely resemble each other clinically. Sarcoma develops in children and in persons of middle age. It often grows rapidly, and varies in malignancy according as do itshistologic components. Usually spindle-celled or large-celled or round-celled, it may exist as a single tumor, or there may be multiple tumors. Freciucntly there are mixed forms of sarcoma, such as fibrosarcoma, and some of these tumors are 1 P. Thorndike and J. H. Cunningham, Hypernephroma, Boston Med. and Surg. Jour., December .3, 1903. TUMORS OF THE KIDNEY AND SUPRARENAL GLAND 385 relatively benign. Then there is the angiosarcoma which goes by various names, endotheUoma among others. Sarcomata do not often bleed. They rarely obstruct the ureter. They invade the veins — especially the renal vein — and deposit metastases in distant parts of the body. Rarely sarcomata may be bilateral. Ordinarily, when one kidney only is affected, an attempt at its extirpation should be made, though this is possible early in the disease only. In this connection G. Walker ^ advocates tying the renal vessels by transperitoneal section before removing the kidney through an extraperitoneal route. One opens the abdomen in the median line, seeks the renal vessels, and cuts down upon them through the posterior peritoneum; then secures them by double ligatures, closes the peritoneum, and attacks the kidney by the lateral-flank or lumbar incision. These malignant tumors are best removed by an extraperitoneal route, for transperitoneal extirpation shows a 3 per cent, higher death-rate. At the best the outlook for sarcoma of the kidney is grave. Carcinoma of the kidney is another rapidly fatal disease. The growth originates in the uriniferous tubules and gradually destroys the parenchyma, invading in turn the renal vessels, the ureter, and, rarely, the bladder. Though sometimes primary in the kidney, cancer is much more often secondary there. It is characterized by pain, hemorrhage,' cachexia, and metastasis. Sometimes, if situated in the upper pole, it cannot be recognized until far advanced; but when in the lower pole, it is palpable early. Extirpation is the only logical treatment for renal cancer, though the outlook is even more grave than in the case of sarcoma, and the opera- tive mortality-rate is as high as 50 per cent. There are numerous non-malignant tumors of the kidney, but they are relatively rare, and often are not discovered clinically. A long list of such tumors is given by compilers of statistics: fibroma, lipoma, osteoma, chondroma, angioma, and lymphangioma, all of which cause symptoms through their size and by compression of other organs. It is impossible to differentiate them, but they may be treated success- fully by nephrotomy or nephrectomy. There are also cystic tumors of the kidney. Simple cysts show little tendency to destroy renal tissue, and are, therefore, harmless. Echinococcus cysts are uncommon. They develop slowly and give little pain. The diagnosis is impossible unless one of the cysts bursts, when daughter-cysts and booklets may be found in the urine. The disease is cured by incision and drainage in a considerable proportion of cases. Polycystic degeneration may transform the kidney into a mass of cystic spaces, large and small, with obliteration of parenchyma. The process may be congenital ^ or may originate late in life and run a chronic course. The disease is bilateral usually. Nephrectomy is permissible in case the opposite kidney is proved competent. Probably the best operation is 1 Jour. Amer. Med. Assoc, November 25, 1905. 2 See especially F.B. Lund, Congenital Cystic Kidney, Jour. Amer. Med. Assoc, August 18, 1906. 25 386 GENITO-URINARY ORGANS nephrotomy: a breaking up of the cysts and suture to the himbar muscles, with packing and abundant drainage. A clas^sification of tumors of the suprarenal glands is still imperfect. Probably 80 per cent, of suprarenal lesions are tuberculous. There are rare cases of primary cancer and sarcoma/ Avhile adenoma is more com- mon. Adrenal cysts occasionally are reported, while adrenal hema- toma in the new-born is not uncommon. Some adrenal cysts may attain great size and require an extensive surgical operation for their removal. If complete extirpation is impossible on account of hemorrhage and ex- tensive adhesions, the surgeon may resort to marsupialization.- LUMBAR FISTULA Fistula in the renal region may be a cause of obstinate, dangerous, and distressing symptoms. There are various types of these fistulse. Some of them are not connected with the kidney. Perhaps the fistula most commonly seen is that which persists after a surgical operation — generally, a nephrotomy for hydronephrosis or for calculus. FistuljE may be associated w^ith tuberculosis. The presence of a calculus, of diseased cystic renal walls, of tuberculosis, or of ureteral stone may cause fistulse to persist indefinitely. Those fistuke which do not communi- cate with the renal apparatus may mark the site of an old parane- phritic abscess. Curious internal fistulse are seen sometimes — fistulse connecting the kidney with the intestine (intestinorenal, usually colon) or with the stomach (gastrorenal) ; and in these cases pus and urine will escape by the rectum, or undigested food may be passed from the bladder. The treatment of these intricate conditions is by painstaking and laborious operation. The urinary passages must be explored, foreign substances removed, necrotic tissue excised, and kidneys, tuberculous or obstinately diseased, must be extirpated. At the same time the fistulous track must be explored and damaged viscera repaired. CHRONIC NEPHRITIS Within the last ten 3-ears decapsulation of the kidney has been employed for the cure of chronic nephritis. Ferguson has made some interesting and valuable observations on the subject, while Edebohls, in vigorous language, has advocated the measure. Many operators have experimented with kidney decapsulation for renal inflanmiations, so that the statistical reports now at our disposal are considerable. Unfortunate!}', conclusive evidence as to the value of decapsulation is not yet before us. There seems to be little doubt that many cases have been improved, and that some few cases have been cured, by this man- euver; but the final application of the measure to definite conditions is not yet clear enough to be taught in a brief treatise of this nature. 1 See Ramsay, Johns Hopkins Hosp. Bull., 1902, vol. x. 2 Cysts of the Suprarenal Gland, Andrew J. McCosh, Ann. Surg., June, 1907. (HKONIC NEPHRITIS 387 The technic of kidney decapsulation is extremely simple. The surgeon approaches the kidney through a lumbar incision, as though he purposed nephropexy. He seizes and extracts the kidney, splits the fibrous capsule, peels it off, and removes it as far down as the renal vessels. He then drops back the kidney into its place. The nature of the histologic changes which follow in the course of healing is still under discussion, and numerous ingenious observers have advanced various views. Whatever takes place, it is certain, as I have stated, that relief sometimes ensues, owing probably to the removal of pressure from the tense kidney tissue. In the foregoing pages I have outlined the most frequent pathologic conditions in the kidney which concern the surgeon. Often they are related closely to disturbances in other parts of the urinary tract, and I shall, therefore, in the next chapter, continue the discussion, dealing especially with diseases of the bladder and prostate gland. CHAPTER XIV BLADDER AND PROSTATE The Bladder Through the development of surgery it has come about that the bladder interests surgeons less than it did in the last generation. In current periodic literature discussion of bladder diseases is not conspic- uous, yet in my student days stone in the bladder was held to be one of the most important subjects of surgical investigation, and the literature of vesical calculus was enormous. Doubtless this interest was due- in part to the genius of Henry J. Bigelow, who then recently had thrown upon the subject a flood of light, and had advanced the operation for stone from its long-time perilous position to a situation of safety and certainty. All that is now ancient history. Surgeons are somew'hat tired of bladder problems. The bladder is not a vital organ, so that the pres- ervation of its structure and function is less urgently important than is the case with the kidney and the intestine. Indeed, individuals can get along without a urinary bladder. Unfortunate wretches are not infrequently born without a proper bladder. Such persons present the condition known as exstrophy of the bladder. EXSTROPHY OF THE BLADDER This curious condition, which amounts practically to an absence of the bladder, is a congenital defective development seen more commonly in male than in female infants. The anterior abdominal wall fails to close, and the anterior v.'all of the bladder is absent, so that the pos- terior bladder-wall, with the openings of the ureters, presents. The arch of the pubes is undeveloped, epispadias exists, and frequently the testicles do not descend. As a result of this condition the posterior vesical mucosa protrudes into the outer world, and urine constantly dribbles from the exposed ureters. The condition of the victim is loathsome. There are various degrees of exstrophy, from a mere trifling open- ing or cleft in the lowest portion of the bladder to a wide furrow, exposing bladder, urachus, and urethra. It is obvious that the condition is found in poorly developed and congenitally defective subjects, and one ques- tions sometimes whether the lives of the unfortunate victims are worth saving. The only reasonable treatment consists in some form of surgical operation which shall confine the urine in its normal channel, or at least divert it from constantly flowing over the parts. The names of sundry 388 ABSENCE OF HLADDEIi; DOUBLE BLADDER 389 distingui.shc(l siirfj;eons have been connected with endeavors to relieve exstrophy of the hhulder. Until recently the aim of all was to restore the anterior bladder-wall by turning skin-fhips over the defects — skin- flaps with the epithelium turned in. These efforts have not been satis- factory. A continent bladder practically never is secured in this manner. Trendelenburg advocates bringing together the separated pubic bones after dividing the sacro-iliac synchondroses. Tlie maneuver is hazar- dous, and the results uncertain. Certain surgeons advocate removing the bladder altogether and implanting the ureters in the urethra. This operation is not difficult, nor is it dangerous. It confines the urinary stream to a normal passage, from which the continual drippings may be collected in a suitable urinal. Of recent years a more radical operation for exstrophy has been advocated by various ingenious writers, and their questionable successes have roused some spasmodic enthusiasm. Simon, Maydl, Gersuny, Hochenegg, Peters, Rutkowski, and .others have advocated extirpating the bladder and implanting th« ureters in the rectum, the sigmoid, or the ileum. Maydl's method is intraperitoneal; Peter's method is extraperitoneal, and there are sundry modifications. The ureters with a portion of the trigone are excised and implanted within the gut. Bottomley advocates vigorously the implanting of the ureters in the skin of the loin behind the kidneys. Experience shows that urine escaping in the back is easily collected in a suitable apparatus, to the great comfort of the patient. As a secondary step in his operation, Bottomley excises the remnant of the bladder.^ Several of these patients have recovered and have led fairly comfortable existences for a time. Probably some form of transplan- tation operation is the operation of choice, though the cases are as yet too few for us to know definitely the probable mortality from ascending pyelitis, the tolerance of the bowel, and the competency of the anus in those cases in which the ureters are implanted in the rectum. ABSENCE OF BLADDER; DOUBLE BLADDER Two other rare anomalies of the bladder are congenital absence of the bladder and double bladder. The most common lesions of the bladder are inflammations, calculus formation, and tumors, and the most noticeable and important symp- tom for ^vhich the surgeon is consulted is retention of urine due to some obstruction to the bladder's outlet. As with the kidney, similar bladder symptoms may be due to divers causes, while similar causes may produce various symptoms; retention of urine may be due to stricture of the urethra or to prostatic hypertrophy, while stricture of the urethra may cause no other symptoms than frequency, and prostatic hypertrophy may be devoid of all symptoms whatever. Let us consider first the familiar symptom, retention of urine, and after that, the conditions which give rise to retention. 1 John T. Bottomley, Operati^-e Treatment of Exstrophy of the Bladder by Transplantation of the Ureters on to the Skin of the Loin, Jour. Amer. Med. Assoc, July 13, 1907. Bottomley gives an excellent bibliography also. 390 GENITO-URINARY ORGANS RETENTION OF URINE The condition of retention is an abnormal collection of urine within the bladder due to the more or less complete obstruction of the natural outlet. We recognize comi)lete retention and ])artial retention, par- tial retention b(Mng the more common, for complete retention must be regarded generally as the last stage of a long-continued partial retention. A majority of cases of retention are due to some such obstruction as I have mentioned, — obstruction of the urethra, — though there is a second, rarer variety of retention in which the condition results from some diminution of vigor in the expulsive forces — some paralysis or other. Urethral stricture and prostatic enlargement are the most common causes of obstruction. In addition, retention may be due to acute inflammation causing swelling and choking of the urethra; to prostatic tuberculosis; to concretions; to abscess or tumors; to lacera- tions of the urethra, or to blood-clots and foreign bodies. Some modi- fication of nervous force diminishing the expulsive power of the bladder gives rise to a common form of retention. For example, many persons, while lying on the back, cannot void urine; operations upon the abdomen and pelvis frequently cause such temporary retention. Moreover, there are the more general causes which, through sundry diseases, affect the tone of the bladder, and there are special diseases resulting in paralyses — such diseases as brain tumor and paresis. If the surgeon finds a j^atient with urine dril)bling drop by drop from the urethra, he must not con- clude that retention is absent, but must regard this dribbling as the overflow of an incompetent and overdistended bladder. In such case the presence of the distended bladder usually is obvious. It feels like a tense, smooth, football-like tumor, rising from behind the pubes as far as the navel often. The surgeon must distinguish carefully retention from suppression of urine. In the latter case no urine collects in the bladder; and he must recognize rupture of the bladder, in which case urine cannot pass through the urethra, but is disseminated through- out the soft tissues of the pelvis, a condition known as extravasation of urine. The reader will see from this description of retention that its mani- fold causes demand manifold treatment. The nervous cases often can be set right by some simple device — by applying hot, wet cloths over the bladder and perineum, so as to relax spasm; by immersing the pa- tient in a warm bath and directing him to pass urine in the tiib; by the suggestion trick of pouring water slowly from a height into a basin; by giving a small opium suppository (gr. ^), or even by allowing the patient, if proper, to sit up or stand for a few minutes. Such devices, however, often fail, in which case, as well as in cases of organic obstruc- tion, it is necessar}^ to resort to the common panacea for retention — catheterization. When there is no obstruction in the urethra, it is easy usually to pass a catheter, and the best instrument for general use is the flexible soft-rubber catheter (No. 8, 10, or 12, English size). In the case of a RETENTION OF URINE 391 woman, the nurse must have the patient's thighs widely separated, and must part the vulva with the fingers, when the pouting orifice of the urethra will appear immediately above the vaginal outlet and below the clitoris. Then the catheter, sterilized by boiling and well lubricated, readily may be passed into the bladder. Neglect of these various details leads often to trouble and misery. Not long ago I was called hastily to a suburban sanatorium, in the middle of the night, by the physician resident there, who informed me that he wished me to see a maniacal woman who was in agony with an overdistended bladder, which he was unable to relieve. On reaching the patient's room I had her brought to the edge of the bed, and held firmly in the lithotomy position. Then, upon parting the vulva, with a good Hght behind me, I had no difficulty in emptying the bladder at once with an ordinary soft catheter. It appeared that the physician had attempted the maneuver aided by the sense of touch only, and had succeeded merely in passing the catheter into the vagina. If for any reason a soft catheter fails to pass, it is well to try a gum-elastic instrument or a glass or silver catheter. In the case of a man with spasmodic retention, thq passage of the catheter generally is extremely easy. The soft-rubber instrument suffices and can be carried quickly and directly to the bladder without difficulty.^ The student will learn the use of catheters in his dispensary studies and from text-books on operative surgery. Suffice it here to suggest a few principles : so far as possible use soft catheters ; never employ force ; remember that, in the male, the penis is held in such a position that the urethra resembles in its course the letter J ; an extremely service- able catheter is the so-called English gum-elastic, carrying a stilet which can be bent to any desired angle; the so-called coude catheter, which has an obtuse elbow near the beak, is a useful instrument also; the silyer catheter is not often used in these days ; the beak of a catheter meets obstiTiction just beyond the bulbous urethra, and often, in old men, in the prostatic urethra; to pass these obstacles the beak should be elevated by lowering the shaft, and in the case of prostatic obstruc- tion, a catheter with a pronounced S-shaped curve generally will enter the bladder; a familiar maneuver which aids in passing by a prostatic obstruction is to introduce the full-curved gum-elastic instrument as far as it will go and then to withdraw the stilet about an inch, when the ^ As to a lubricant: ordinary carbolized vaselin or glycerin suffices, but since these materials, when frequently used, may damage the texture of a catheter, some such lubricant as the following, suggested by Gouley, may be employed: Powdered white Castile soap 1 ounce Mucilage of chondrus crispus 3 ounces Formalin (40 per cent, solution formaldehyd) 10 minims Thymol 5 grains Oil of thyme 5 minims Alcohol 15 minims Heat the soap and water and stir until smooth. Add the mucilage (one ounce of chondrus crispus to one pint of water) ; when cool, pour in the formalin and then the thymol and oil of thyme mixed with the alcohol. Put up in two collapsible tubes -and sterilize. 392 GEXITO-UUIXAUY ORGAN'S beak of the catheter springs u])\vard and fonvard and enters the bladc^er. Catheters must be made scru})ulously aseptic before their use, and for this purpose boihng, or immersion in 1 : 3000 corrosive subhmate solution, generally suffices. I have not considered here in detail the Fig. 239. — Passing the male sound or catheter (Hyde and Montgomery). pathologic conditions, such as stricture, which may produce an imper- meable urethra causing retention, but I shall speak of these conditions under appropriate headings. Should the surgeon be unable to pass a catheter into the bladder, he may find it necessary to puncture that organ. This operation is Fig. 240. — Passing the male sound or catheter (Hyde and l\fontgomery). easy if properly undertaken. Remember that you are dealing with a distended bladder rising well above the pubes. Such a bladder, as it rises, carries before it and above it the peritoneum, so that there is left a small space, from one to three inches in extent, above the pubes, RETENTION OF URINE 393 where the bladder is uncovered of peritoneum. The surgeon punctures through this space. It is well first to anesthetize the skin in this region bv injecting a few drops of 2 per cent, solution of cocain, so that the operation of puncture may be painless; then, with a four-inch straight Fig. 241. — Passing the male sound or catheter (Hyde and Montgomery). or shghtly curved trocar and cannula, stab quickly into the bladder, hugging the pubic symphysis. Withdraw the trocar and allow the urine to escape through the cannula. It is an old teaching that the total amount of urine should not be withdrawn all at once, either by catheter or cannula, from a greatly distended bladder, as the sudden rehef of Fig. 242. — Passing the male sound or catheter (Hyde and Montgomery). pressure causes a great engorgement of the venous plexus about the bladder, with frequent hemorrhage into that organ and occasional collapse. The urine should be drawn off slowly, about one-half at a time, that the veins may accommodate themselves to the condition of 394 GENITO-rUIXAUY ORGANS altered pressure. Under certain circumstances, that is, when it is obvious that a recurrence of retention may follow the temporary relief, it will seem wise to the surgeon to institute pei-mancnt drainage, either by fastening a catheter into the urethra, or a cannvda, passed above the pubes, into the bladder. Fig. 243. — Suprapubic puncture of the bladder. All these suggestions deal with intricate and perplexing problems difficult of satisfactory elucidation in a brief writing. In order to become familiar with these problems and their solution the student must serve a proper apprenticeship under the direction of an expert. CYSTITIS Cystitis is a constantly present feature in all diseases of the bladder, and is an extremely frequent complication of other genito-urinary disturbances. One often feels that inflammation of the bladder is almost the commonest form of mucous membrane inflammation. We encounter it in. connection with all sorts of general infections, such as typhoid fever or pneumonia, besides which it is due to local causes. The pathologist describes 3 types of cystitis: (1) Superficial cystitis; (2) interstitial cystitis; (3) productive cystitis. Clinirally, the most fre- quent forms observed are— (1) Gonorrheal cystitis; (2) tuberculous cystitis; (3) the cystitis of urethral stricture; (4) calculus cystitis; (5) CYSTITIS 395 cystitis of tumors; (G) cystitis of prostatic origin; (7) cystitis of instru- mentation. It is impossible often to determine accurately the exact clinical type of cystitis with which one has to deal, but, in fact, the symptoms are much the same in all, for the disease is of bacterial origin and bacteria of similar character are present in all types — the bacteria of suppuration, colon bacilli, and, more rarely, typhoid bacilli and pneumo- cocci. Some authorities still maintain that exposure to cold is a cause of cystitis, but even granting this, such exposure acts merely by reduc- ing the resisting power of the tissues, so that organisms more easily find lodgment and work havoc. So far as our understanding the type goes, the definitions^gonorrheal, tuberculous, etc. — carry their own explanation. Gonorrheal cystitis obviously is an extension of a gonorrheal process from the urethral mucosa. Tuberculous cystitis, like gonorrheal cystitis, is secondary, as a rule — secondary to tuberculosis of the kidneys, the prostate, the seminal vesicles, or the epididymis. Tuberculous cystitis generally runs a chronic course. The symptoms of tuberculous cystitis are particularly important, and the gravity of the condition is great. You will observe increasing frequency of micturition, especially during the day, but later at night as well. There are often penile pain, bladder tenesmus, and, sometimes, a shutting off of the stream, with great distress. All these symptoms are wont to grow steadily worse in spite of the ordinary methods of treatment. Indeed, the drug, urotropin, commonl}- useful in other forms of cystitis, seems to work positive damage in tuberculous cases. The diagnosis of tuberculous cystitis is made certain by finding tubercle bacilli (to be distinguished from smegma bacilli) in the urinary deposit. Sometimes it is necessary to examine with the cystoscope, when the bladder mucosa will show at first infiltrated areas and ecchymoses, and later numerous circular ulcers. The cystitis due to urethral stricture needs no special explanation, nor does the cystitis of calculus, except to remark that when a stone forms in the bladder, the formation follows a cystitis, while a bladder calculus of kidney origin precedes and causes the cystitis. Tumors and prostatic enlargements are wont to obstruct the outflow of urine, and to damage more or less seriously the bladder-wall, changing its stmcture and tone and so favoring the lodgment and development of bacteria. An extremely common cause of cystitis is instrumentation — the introduction into the bladder of infective organisms on catheters, sounds, and other instruments. It is difficult to prevent such infections, for a carefully cleaned catheter may pick up organisms from the vulva and urethra. Obviously, and for this reason, these parts should be cleaned, so far as possible, by bathing and by boric-acid irrigations. The S5anptom which always suggests cystitis is frequency of mic- 1 urition ; then comes pain, during and after the act of micturition (ten- esmus, the painful contraction of the bladder sphincter, with straining 396 GENITO-UiaXARY ORGAN'S and a sense of continued desire for micturition) ; pus is usually found in the urine; rarely there is bloody urine (hematuria). The increased frequency and the pain are constant factors, and these symptoms are greatest when the patient is upright and moving about. Observe that frequency due to prostatic enlargement is greatest during the night. The inflamed mucosa is extremely sensitive to irritation, whereas the mucosa of the normal bladder is surprisingly tolerant. It is for the former reason that frequcnc}- arises, and the irritation is so pronounced that even after the passage of urine desire and tenesmus persist for some minutes. Early in the disease the urine may be acid when passed, but upon standing its contained bacteria multiply and alkalinity fol- lows. Late the urine when passed is alkaline and is loaded with pus and bacteria. In acute cystitis, accordingly, we see these symptoms and signs : frequency, pain, and pus. Later, the disease may become chronic. The superficial inflammation gives place to the interstitial inflamma- tion. The bladder becomes more or less thickened and permanently contracted. Sacculation or the formation of pockets may occur. The symptoms are then less urgent, though still constant. The dim- inished bladder must be emptied frequently; the tenesmus is less, but there is superadded a sense of burning and weight in the perineum; occasionally blood is passed, and the urine will be found to contain not only pus and bacteria, but ropy mucus, which settles in the urine glass and clings to the side of the vessel. Any albumin which may be present is due to the blood or concurrent renal disease, and is not due to the pus. The picture presented b\' patients suffering from cystitis is distress- ing. They are wretched, constantly uneasy, in pain, with appetite diminished, sleep interrupted, and general health rapidly breaking down. Fortunately, the treatment of C3'stitis is effective in most cases, except in tuberculous patients and in those suffering from concurrent ulceration of the bladder. From what I have said it is obv-ious that the causes and complications of cystitis, as well as the disea.se it.self , must be considered and treated. Gonorrhea, stone, stricture, must severally be dealt with. Setting aside for the moment a consideration of the underlying causes of cystitis, we may regard those mea.sures which relieve the symptoms and may be looked to for a cure of cy.stitis when uncomplicated. For the pain and frequency opium is the best di-ug, and ordinarily it should be given by the rectum, in 1-grain suppositories. Hot ap- plications over the pubes are an additional comfort, as is also immersion in a hot bath, when urine may be passed in the bath with little distress. The bowels should be kept open by salines and enemata, and the diet should be limited to milk, if the patient will bear it. In chronic cases one should allow a somewhat more liberal diet. At the same time cer- tain diuretics are u.'jeful ; best of all, urotropin. in T^-grain do.ses, with plenty of water, eveiy four to six hours. When the patient can bear it, irrigations of the bladder are useful in order to wash out the pus and mucus. Frequently it is necessary to cocainize first the urethra. CYSTITIS 397 Ordinarily, there is no better irrigating fluid than a 4 per cent, boric- acid sokition, which should be injected reasonably hot, the injections being repeated until the solution returns clear.^ Sometimes the bladder will not tolerate irrigation, in which case instillations may be sub- stituted, a few drops of argyrol (10 per cent.) being introduced with a Keyes syringe gently into the deep urethra. Occasionally, in extremely obstinate cases of cystitis, and as a prehminary to more radical measures, it is well to institute permanent drainage for a time. Such drainage is for chronic and not for acute cystitis. Such are the measures generally found effective in the treatment of the inflamed urinary bladder. There is another condition, commonly called irritable bladder, Avhich must always be distinguished from cys- titis. Irritable bladder is a general and indefinite term. It is common in neurotic women who complain of frequent calls to urinate and of inability to suppress a sudden gush of urine. Sufferers from nephro- lithiasis and gout also have irritable bladders— so do typhoid patients or any persons who secrete a scanty, concentrated urine. Such tumors as uterine myomata and ovarian cysts irritate the bladder. Irritable bladder often runs into that condition known as incontinence of urine, in which, for some cause, the bladder suddenly finds itself unable to retain its contents. As Fowler says, " in the true sense the term is applied to cases in which the urine escapes as soon as it reaches the bladder." These are the cases in which the bladder is paralyzed. Every surgeon who has had to deal with cases of '■' broken back"' is familiar with incontinence of urine. We see then that urinary incontin- ence may be due to serious central lesions, or it may be due to some habit neurosis. Nocturnal wetting belongs to the latter class, and is particu- larly common in little boys. The treatment of incontinence depends upon the cause, and the milder cases only can be treated directly. Sometimes wornen who are so troubled may be cured by a stretching of the urethral sphincter, while mental suggestion is of great value, especially through directing the patient to prolong the intervals between micturitions. Excessive acidity of the urine must be corrected by giving such alkaUs as po- tassium acetate; while phimosis, balanitis, stricture, stone, pin-worms, and overheating with a multitude of blankets must be met by appro- priate operations and suitable hygienic directions. Sometimes, for the nocturnal incontinence of children, benefit is found through elevation of the pelvis during sleep and giving increasing doses of tmcture of belladonna until the physiologic limit is reached. In the case of adults, belladonna plus strychnin (gr. 4V to t'o) helps. Incontinence yields slowly to treatment at the best, and I have known cases which recov- ered after long-continued change of residence or a distant sea-vogage only. 1 This description applies to non-tuberculous cystitis of the male bladder. The treatment of such cystitis in the female bladder is still more simple and ettective. See Edgar Garceau, Treatment of Tubercular and Non-tubercular Cystitis m the Female, Amer. Jour. Obstet., 1907, vol. Ivi, No. 3. 398 GENITO-UHINAUY ORGANS STONE IN THE BLADDER Stone in the bladder seems to be less common in this country and at the present day than as described by former writers. In some parts of the world it is still frequently encountered, especially among eastern peoples, among whom operators for stone find a large practice. The removal of stone is one of the most ancient of surgical operations. It is mentioned in the oath of Hippocrates, who protests that he will not himself perform the operation, but will leave it to those whose proper business it is. We count as stone proper those vesical concretions which the bladder cannot expel through the urethra. These stones are usually made up of either uric acid and its salts, of oxalate of lime, or of phosphates or carbonates, sometimes combined with urate of ammonia. These various groups may be associated in the structure of a single stone or the stone may contain a single ingredient. Moreover, salts may be deposited about some albuminous substance, or some foreign body, which acts as the skeleton or nucleus for the calcareous collection. The causes of stone formation are various and sometimes not al- together obvious. The disease is thought to be inherent in certain families, while diet and habit are factors often. Sundry diseases result- ing in malnutrition, such as gout and liver diseases, predispose to stone formation of the uric-acid type, while phosphatic stones are the result of local conditions, such as alkaline fermentation of the urine from chronic cystitis, or retention of mine from any cause — prostatic en- largement, tumor, stricture, and the like. Finally, a renal stone discharged into the bladder may lie there and take on additional de- posits. The symptoms of stone in the bladder are not always character- istic; they may be extremely puzzling, and they may suggest some other lesion. The old-time questions put to a patient were: " Do you pass blood at the end of micturition?'' and " Does driving over a rough road cause pain in the perineum? " A positive answer to these questions is suggestive merely. A patient may carry several large smooth stones in his bladder with little discomfort. On the other hand, one small rough stone may cause intolerable agony, especially when the patient moves about. Such a stone ma\' have come down from the kidney with symptoms of renal colic, and may continue to cause discomfort and pain after it reaches the bladder. Stone in the bladder is more common in males than in females, so that most of the literature on the subject deals with the cases of men and boys. Accordingly the pain is frequently referred to the neighborhood of the glans penis, a little behind the meatus and below it, but pain is not invariable, and its absence does not prove the absence of stone. The pain is due commonly to contraction of the bladder about a stone. Sometimes it is due to irritation of the bladder mucosa by a rough stone. Frequently, cj'stitis is associated with stone, in which case the symptoms of cystitis may overshadow the symptoms of calculus. The passage of a few drops of blood at the end of mic- STONE IN THE BLADDER 399 turition is presumptive evideiu-e of stone, but it is not a constant sign. A sudden shutting off of the stream during micturition sometimes occurs and is due to a stone's falling over and obstructing the internal urethral opening. In men with enlarged prostates this does not occur, as in such persons the stone ahvays sinks behind the prostate to the bottom of the bladder. In operating within the bladder for conditions other than stone, stones previously unsuspected often are discovered, for the presence of such calculi is masked by symptoms of cystitis, by bladder tumors, by prostatic enlargements, or by sacculations within which the stone may lie concealed. The symptoms of stone, however, never demonstrate a final and positive diagnosis. The surgeon must feel and hear the impact of a sound upon the calculus; and if this does not suffice to clear up the diag- nosis, he must inspect the bladder through the cystoscope. Sounding for stone is sometimes a delicate and difficult minor operation, not care- lessly to be undertaken. It is best done with the patient lying on a harci table. As a first step one should thoroughly wash out the bladder with boric-acid solution, and should leave a small quantity of the solu- tion in the bladder— 2 to 3 ounces in a child, 8 to 12 ounces in a man. The patient's hips should be somewhat elevated, and a sHghtly curved sound or stone-searcher should be introduced through the urethra, previously cocainized. It is a needless barbarity to search for stoiie without having given some anesthetic, besides which the anesthetic keeps the patient quiet and makes easier the surgeon's work. Usually the stone, if present, is felt lying at the bottom of the bladder, a httle below the internal meatus. Sometimes an elusive stone is brought to the beak of the searcher by a finger in the rectum, elevating the bladder. Sometimes the stone, overlaid with mucus, escapes entirely the exam- ining touch. Sometimes a suspected stone is discovered by w^ashing the bladder with a Bigelow evacuator, w^hen a sudden checkmg of the stream or " fish-bite," proclaims the presence of a stone. Kot infrequently, a second or third examination is necessary in order to detect the stone, but always after the first examination it is well to employ ether anes- thesia, if all these methods fail and the presence of stone is still strongly suspected, one should search for it with the cystoscope. By "^ whatever method a stone is found, its size should be deter- mined, either bv measuring with the searcher, or, roughly, by visual cystoscopic inspection. Should aU other methods fail and stone or other serious bladder lesion still be suspected, the surgeon may be justified in exploring the bladder through a suprapubic cystotomy. In the case of thin women and in yoimg children it is often possible to palpate a stone bimanually, with one finger in the vagina or rectum and a hand above the pubes. The treatment of stone in the bladder is a subject older than his- torv, as I have intimated, and from the earfiest times even fairly rational methods of extracting calculi have maintained. Obviously, a simple and straightfoi-ward manner of opening the bladder is the old one of 400 GEXITO-IRINARY ORGANS passing a staff, or sound. tlii()U<:li tlic urethra and cutting upon it, by the perineal route, until the hhukler is opened. That was anci(!nt prac- tice. In more modern times the bladder was oj^ened by the lateral perineal route, a method still employed occasionally. Another ancient practice, popularized in recent years, is suprapubic opening of the bladder, while a fourth method, in great vogue during the past thirty-five years, is to crush the stone within the bladder by instruments introduced Fig. 244. — Litholapaxy; crushing the stone (diagrammatic). through the urethra, and to wash out the fragments. This last procedure is known as litholapaxy. Litholapaxy. — Jean Civiale, in 1824, was the first successfully to per- form the operation of crushing a stone. ^ He did not wash out the frag- ments but left the patient to pass them. Many experimenters worked 1 Lithotrity: crushing a stone. Litholapaxy: lithotrity followed by prompt removal of fragments of the stone through a tube, by suction. STONE IN THE BLADDER 401 to perfect a better tcchnic, until Henry J. Bigelow, in the last quarter of the nineteenth century, developed the modern operation, crushing and evacuating at a single sitting — litholapaxy. For the general surgeon, and with suitable cases, litholapaxy is the operation of choice. The tcchnic of this procedure was graphically described by Bigelow in a brilliant series of articles published in 1878 and subsequent years. The instruments required are lithotrites of various sizes, and an evacuat- Fig. 245. — Diagram showing Bigelow's evacuator in place. ing apparatus, such as is pictured in the text. Patients wdth im- permeable stricture, with extremely hard calculi, wdth encysted stone, or with great prostatic enlargement, are not fit subjects for litholapaxy. In no case should the operation be performed hastily. The patient should be kept in bed for five or six days previously, on a limited diet, with abundant drinking of water and of milk, and any existing cystitis should be treated by urotropin and irrigation. Indeed, litholapaxy should not be undertaken in the face of an active cystitis. On the 26 402 GENITO-URIXARY ORGANS operating table the patient should be tipped u]) in a modified Trendelen- burg position, the urethra and bladder should be thoroughly irrigated, while 6 or S ounces of boric-acid solution (4 per cent.) should be left in the bladder. We are now ready for the actual crushing. The surgeon introduces a lithotrite, of the Bigelow or Forbes pattern, letting it glide gently into the urethra and passing the prostate without force. When the instrument is in the bladder, the handle should be depressed to an angle of about 30 degrees with the table, and with the beak up- ward, the instrument should be made to he at the bottom of the bladder. The jaws are opened by pulling back the male blade. The surgeon waits for a moment until all currents have subsided, when the stone usually will be found to have fallen between the blades. It is then seized and crushed and the larger fragments are crushed again in turn until the whole mass has been reduced to gravel. After that the lithotrite is withdrawn, when the surgeon introduces the evacuating tube and washes out the fragments. This part of the operation must be performed carefully and thoroughly, so that no fragments be left to form the nucleus of a new stone. Throughout the operation, especially when using the lithotrite, the surgeon should make all movements care- fully and gently, taking pains especially not to cru.sh the stone until it is firmly grasped and not to pinch the bladder-wall within the jaws of the instrument. The after-treatment is usually simple, and amounts to little more than keeping the patient in bed for a week, administering morphin for the early pain, and giving a light diet, with plenty of water. If retention, fever, or cystitis supervene, they must be met by such appropriate measures as catheterization, the administration of quinin and mor- phin, and daily irrigations of the bladder. The mortality from lithol- apaxy in proper cases is low, and even in children it is the best opera- tion for routine practice. Suprapubic cystotomy for stone is frequently employed. It is indicated in the cases of urethral stricture, of great prostatic enlarge- ment, and of hard and multiple stones, as well as when stones are en- cysted and inaccessible to the lithotrite. The preparation is similar to that for litholapaxy, and the operation is facilitated by elevating the patient to 45 degrees in the Trendelenburg position, and introducing a distensible bag or colpeurynter (with which some surgeons prefer to dispense) into the rectum, in order to elevate the bladder above the pubes. From 4 to 8 ounces of boric-acid solution are then injected into the bladder to raise it further, so as to simplify the dissection and to roll back the peritoneum. Recollect that an anterior fold of the peritoneum falls over the collapsed bladder, while a full bladder pushes the peri- toneum upward and out of the way. I recommend a transverse in- cision at the upper edge of the pubes through the skin and aponeurosis, as I have found that such an incision, when healed, gives a sense of perfect support to the abdominal wall, AA'hen the surgeon has dissected well back and separately the skin and aponeurosis, he splits the space between the pyramidales muscles and enters at cnce into the prevesical STONE IN THE BLADDER 403 space. Sometimes it is necessary to cut away from the pubes the muscle attachments. There is no excuse for blundering into the peritoneal cavity. Upon opening the prevesical space, dissect bluntly with the fingers down behind the pubic arch and distinguish the outline of the bladder; then explore it by pushing back the fat, and seize the bladder- wall with forceps or tenacula. Draw up the bladder, fix it firmly in the wound with tw^o provisional stitches, one on either side of the median line, and held by an assistant. Then open the bladder, dissecting back the muscularis from the mucosa, and opening separately each layer. The bladder should previously have been packed off with gauze pads from the surrounding tissues. Evacuate the contained fluid, open the Fig. 246.— Suprapubic bladder drainage. viscus w^idely with retractors, and inspect its anterior by the aid of a head-mirror and reflected light. Frequently gauze sponging with mops or sweeps may be necessary. It is now an easy matter to remove calculi with stone forceps or the fingers, and to perform any further operation which may be indicated. The after-treatment of the woimd is somewhat in debate. I prefer to leave in a tubular rubber drain after sewing up the bladder-wall in layers with plain catgut stitches. I believe strongly in the use of a firmly drawn continuous stitch and not in interrupted stitches. The stitches may penetrate the mucosa, and should be so placed in a double row as deeply to turn in the bladder-wall. The rubber tube, and a gauze wack draining the prevesical space, should be led out through a 404 GEXITO-URIXARY ORGANS stab-wound in the superior skin-aponeurosis flap, well away from the line of incision, thus favoring a rapid and aseptic healing of the orig- inal wound. I make a practice furthermore of tying into the blad- der through the urethra a soft catheter, to insure constant drainage. If all goes well, the suprapubic gauze drain is removed at the end of three days, and the suprapubic iiibber drain at the end of eight days. The resulting wound heals shortly, but the urcthi-al drain is kept in place four or five days after the removal of the suprapubic drain. No further after-treatment is indicated except in the case of com- plications, especially cystitis, which can be cared for readily by through- and-through irrigation from above. The mortality after suprapubic cystotomy for stone is slightly higher than after litholapaxy, but I doubt if this is due to any disad- vantage inherent in the operation itself. The true cause probably lies in the fact that we do the operation of litholapaxy in the simpler ca.ses. The true disadvantage in cystotomy is the longer convalescence — three or four weeks — which it entails. In this place it does not seem necessarj' to describe at length the various operations of perineal lithotomy. They are little practised to-day as compared with the operations already described. As I have stated, the principle of these perineal operations is the cutting into the bladder, either laterally or mesially, upon a staff, through the prostate. The operations in themselves are not particularly difficult, but they involve more or less groping in the dark, and the not infrequent danger of permanent damage to the ejaculatory seminal ducts. I refer the student to the text-books on operative surgery should he wish to study the methods of perineal lithotomy. In women stone in the bladder is less common than in men, and is far more easily treated. Small stones may be removed through the urethra by dilating that passage, seizing the stone in forceps, and ex- tracting it; or litholapaxy easily maybe performed, or suprapubic cys- totomy. I do not advise opening the bladder through the vagina, be- cause that operation occasionally has been followed by a permanent vesicovaginal fistula. In connection with the subject of cystitis and stone I must call the reader's attention to ulcer of the bladder. ULCER OF THE BLADDER This affection is not especially uncommon, and is seen more frequently in women than in men. There are two leading forms of ulcer, the tuber- culous and that caused by erosion from long-continued irritation by stone or cystitis. There are also the small multiple erosions similar to gastric erosions in appearance. These bladder ulcers may cause little trouble, or they may give rise to the most distressing symptoms, such as constant pain and tenesmus, especially after micturition. Sometimes blood is passed mingled with the urine, and there may be general constitutional disturbances. TUMORS OF THE BLADDER 405 The treatment of tubercvilous ulceration is systemic and topical. I have not been able to convince myself that without general treatment local treatment is et^ective; but certain it is that the open-air life and improved hj-giene often work remarkable cures. The diagnosis of ulcer of the bladder can bo confirmed by the cys- toscope only, when areas, sloughing or granulating, usually bleeding, and sharply defined from the surrounding mucosa, appear. The char- acter of the urine is not pathognomonic, but suggests a cystitis merely. The treatment of bladder ulcer in addition to the general hygienic course already suggested, consists in local applications through the end- oscope, and the drug commonly employed is some one of the silver salts. In the case of non-tuberculous ulceration I have often seen rapid im- provement and cure by touching the base of the ulcer with a 10 per cent, silver nitrate solution, and sometimes by the pure caustic even, though the latter may cause great subsequent pain. At the same time patients should be put upon a bland diet, mainly milk and water, and should be given urotropin, 7^ grains every six hours. The same local treatment is of some value in the case of tuberculous ulcers. Furthermore, the injection of iodoform suspended in olive oil is valuable — one dram of iodoform to one ounce of pure olive oil, a dram of this mixture being left in the bladder once daily. TUMORS OF THE BLADDER Tumors of the bladder are among the rarer diseases of that organ, but are extremely interesting from the therapeutic as well as from the pathologic point of view. Often they cause distressing symptoms; they can be removed with difficulty only and they have a high mortality. Watson ^ states that in the case of benign tumors of the bladder even, including myxoma, the operative mortality is 17 per cent., while the operative mortality of cancer is 27 per cent., and that of sarcoma, 63 per cent. ; from which it will be seen that many varieties of tumor occur in the bladder, and that it is dangerous to remove them. From the recent studies of Davis ^ it appears that calculus does not predispose the bladder to tumor. All tumors of the bladder have a peculiar and interesting structure — whether benign or malignant, they tend to assume a polypoid character. This is probably due to the fact that they spring from a contractile base, constantly varying in size and position. There are the benign tumors, papillomata, single and multiple, mostly pedunculated, generally cauli- flower in appearance, with a circumscribed base and little tendency to involve deepty the bladder-wall. A connective-tissue form of this growth sometimes undergoes transformation into sarcoma. Further- more, there are fibrous polypi and myxomata, the former being true pedunculated fibromata ancl myxomata, being generally single and 1 F. S. Watson, The Operative Treatment of Tumors of the Bladder, Ann. Surg., December, 190.5. - Lincoln Davis, Primary Tumors of the Urinary Bladder, ibid., April, 1906. 406 GENITO-l'HlXARY ()U(;ANS resembling nasal polypi. Then there are niyomata, generally single, partially pedunculated, and attaining the size of a small orange even. Of the malignant tumors, sarcoma is exti-emely rare, but carcinoma is more frequent; it is a common bladder tumor. Observe that carcinoma may develo]) out of pai)illoma; that primary carcinoma in its early stages resembles papillonui grossly, but that (juickly it involves deeply the bladder-wall. Carcinoma is found most frequently springing from the trigonum, the prostate, or the urethral orifices, while the non-malig- nant forms of tumor are found anywhere upon the bladder-wall. Ob- viously, cancer of the bladder may be secondary, extending from cancer of the rectum and other organs, or rarely it may be metastatic. \\'atson's studies show that myxomata, which occur generally in young children, have a high mortality and recur quickly after operation.^ The symptoms of tumor of the bladder may be characteristic or they may be extremely confusing, and especially ai-e they to be distinguished from the symptoms of stone, of ulcer, and of enlarged prostate. In the case of all tumors of the bladder the commonest symptoms are hemoj- rhage, frequency, and pain. Hemorrhage, without other symptoms, especially is to be observed. Whether the tumor be benign or malig- nant, it may give rise to the symptom of hemorrhage only, for many months or years — hemorrhage coming at the end of micturition often, sometimes abundant. Often extreme clotting takes place, filling the bladder, so that the patient suffers from retention of urine and tenesmus. There may result a hydronephrosis or pyonephrosis. Moreover, there is often an associated cystitis, which adds to the misery of the sufferer, but the cystitis does not occur early in the disease. And cystitis is the cause of pain, except in the case of cancer. Observe, then, that in differ- entiating benign from malignant tumors of the bladder we find both associated with hemorrhage, while the cystitis and pain are late in the case of benign disease, but are relatively early in the case of cancer. Indeed, in the case of cancer, pain precedes or accompanies the first appearance of blood. In making the diagnosis of bladder tumor we have to difTerentiate between that condition and renal disease associated with hemorrhage, bladder-stone, tuberculosis, and prostatic enlargement. In tumor, the hemorrhage is usually constant and abundant; sometimes it is in- termittent; in prostatic enlargement the frequency of micturition is increased at night; in stone, pain is aggravated by exercise. Analysis of the urine helps in the diagnosis of tumor, for frequently particles of the neoplasm may be discovered in the urinary sediment. Through bimanual examination the indurated base of a cancer may be detected by the finger in the rectum, though benign growths may thus rarely be demonstrated; and observe in this connection that bladder tumors are somewhat more common in men than in women. Moreover, according 1 The following revised classification is that of Davis: (Papilloma. I Sarcoma. Adeno^r* ^- Connective-tissue group; -j pibroma! ^- Muscle group: Myoma. Cysts. I Angioma. TUMORS OF THE BLADDER 407 to sex, visual inspection with tlio cystoscope is facilitated, and in women digital touch through the urethra is made possible. Finally, in the case of tumor, as of stone, a suprapubic cystotomy may be necessary to ascertain the true condition. A notable fact about tumors of the bladder, whether benign or malig- nant, is that, if not removed, eventually they kill the victim. In the case of a benign tumor, he dies of hemorrhage, or renal involvement through obstruction to the ureters, with hydronephrosis or pyonephro- sis. In the case of a malignant tumor he dies a lingering death from extensive disease of the genito-urinary organs and from metastases — and, be it observed, that metastases appear late in the course of bladder cancer — sometimes not until the fourth or fifth year of the disease. It is obvious, therefore, that energetic treatment is necessary, and extirpation of the growth is the only successful treatment. The field is relatively a new one. Either suprapubic cystotomy or transperiton- eal cystotomy w^ith excision of the growth is imperative in all cases. If the disease be benign, and, therefore, superficial, the margin of the dissection need not be wide so long as an uninvolved portion of the bladder-wall be removed with the tumor. Such an operation is not particularly dangerous, and gives a reasonable chance of permanent cure. The rent in the bladder-wall at the site of the tumor should be carefully repaired with a plain catgut suture, which will be softened and absorbed, or expelled, before it can become the nucleus of calculus. In the case of benign recurrence even a secondary operation may be followed by permanent cure. The question of what operation to perform in the case of bladder cancer or sarcoma is not so easily answered. Should the growth be ex- tensive and involve other organs, nothing more than curetage and cauter- ization is proper. By such means hemorrhage is checked for a time, and considerable relief is afforded. But in the earlier cases there is reason to hope that we may secure by excision longer immunity or a permanent cure, and with these cancers, as with all others, we should operate early. Indeed, bearing in mind the possibility of a benign bladder tumor's suffering malignant changes, the surgeon should insist always upon an early, radical operation for all bladder tumors. Hitherto, surgeons have contented themselves with resecting broadly the bladder-wall for cancer, opening from above through a liberal in- cision, and freeing the bladder thoroughly, so far as may be, on all sides of the growth. Sometimes it is well to provide a supplementary ap- proach through the perineum, and I shall have a word to say on this matter when discussing cancer of the prostate. After removing the growth the bladder-wall is to be sewed up in layers, pains being taken not to damage the ureters. In this connection it is interesting to con- sider the important radical suggestion of Watson,^ " that total extir- pation of the bladder and of the prostate, if it be involved in the patho- logic process, be done at the outset in all cases of carcinoma that have not extended beyond the limits of the above-named structures, and in 1 See footnote on p. 406. 408 GENITO- URINARY ORGANS which it is believed that there are no metastases; and that the same measure shall be applied in all cases of benign growths in which recurrence has taken place after a primary operation for their removal." Watson would provide for kidney drainage by bilateral nc))hrostomy, after extirpation of the bladder, as he is convinced that this is a measure less dangerous to renal structure than is implantation of the ureters in the bowel or in the skin. He asserts that the condition of the patient after neplirostomy can be made tolerable by the wearing of a proper receptacle for the collection of urine. I am not aware of any general resort to Watson's operation, but it seems probable that it offers the best chance of life for the patient should he survive the operation. Watson does not advocate bladder removal and nephrostomy at one sitting, but would perform primary nephrostomies on the first and second kidneys, with an interval of a month between, and would extirpate the bladder some weeks later. He would tie off the ureters both from above and from below. Since 1893 the transperitoneal or intraperitoneal cystotomy of F. B. Harrington ^ has been gaining in popularit}-, and is now in common use, I find, in many American clinics. The technic of this operation is simple: the abdomen is opened widely above the pubes; the intestines walled back; the bladder exposed and opened freely through the peritoneum. This opening gives an extremely wide and easy approach to the bladder tumors, which may then be excised with a knife or the Paquelin cauter3^ The bladder is closed in three layers with interiiipted catgut stitches. I have employed with satisfaction a modification of Harrington's method; after the abdomen is opened and the bladder exposed, I have turned down a flap of peritoneum in the shape of an inverted U from the posterior surface of the bladder and have then opened the bladder- wall through a longitudinal incision beneath the flap of peritoneum. As a result of this maneuver the bladder wound, when sewed up, becomes an extraperitoneal wound. In broad terms, it appears that the methods of treatment are still 5w6 judice, and Davis' interesting conclusions are worth quoting: " Surgical intervention at the proper time in the case of peduncu- lated papillary tumors of the bladder offers a very fair chance of long immunity, if not of permanent cure. " The method of surgical intervention to be proposed in these cases is excision of the tumor in toto, with a margin of bladder-wall at its base, including mucosa, submucosa, and muscularis in part: the section need not penetrate the entire thickness of the wall." SACCULATION OF THE BLADDER Sacculations of the bladder are coming to be regarded as something more than surgical curiosities, or conditions suited to palliative treat- ment merely. Bladder sacculations are quite similar in stmcturc to the 1 Charles L. Scudder and Lincoln Davis, Harrington's Operation of Intraperi- toneal Cystotomy, Ann. Surg., December, 1908. BLADDER INJURIES 409 diverticula found in the colon. They are either true sacculations of the whole thickness of the bladder-wall, or, more commonly, they are hernia of the mucosa. If the sacculations are large and saucer-shaped, they give little trouble. Often, however, they are almost polypoid in shape — their lumina being of considerable size, while the entrance from the bladder into the sacculations is small. The symptoms of sacculation are often extremel}- distressing. In it there becomes established chronic inflammation with constant pus- formation, which is persistently forced out into the bladder. Cystitis results; stones may be lodged or may form in the sacculation, and so add to the patient's misery. In general terms, therefore, the symptoms of sacculation of the bladder are the symptoms of a severe chronic cystitis. By the use of the cystoscope alone can the sacculation be dis- covered and the diagnosis established. The treatment is difficult and unsatisfactory often. The only sure method is radical and severe — excision of the sacculation. Approach the bladder by the transperitoneal route; turn down a flap of peritoneum; dissect the bladder free from surrounding structures, especially toward its base; develop the sacculation; excise it; repair the rent with catgut stitches; sew up the peritoneal flap, with a drainage wick led out from beneath the flap to and through the external wound. Institute constant drainage by a catheter in the urethra. If the patient is not too much exhausted by long disease, this operation should restore him to health in from three to four weeks. Besides the bladder lesions already described, the surgeon must be prepared vigorously to treat cases of injuries. BLADDER INJURIES Injuries to the bladder are conditions extremely familiar to every large general hospital. These injuries may be intraperitoneal or ex- traperitoneal, and the intraperitoneal injuries are three times the commoner.^ Up to twenty-five years ago, intraperitoneal ruptures were held to be fatal, and it is within recent times only that we have been able to meet and remedy successfully this alarming lesion. The condition involves rupture of all the coats of the bladder and of the peritoneum, with the escape of urine and blood into the peritoneal cavity, and the symptoms are extremely variable. There may be pro- found shock from the outset, or there may be Httle disturbance at first. In the course of a short time, however, evidence of shock appears — rapid pulse, collapse, pallor, and cold extremities. There is nearly always an associated hemorrhage, and shortly a general peritonitis. Peritonitis and shock are the common causes of death, while death from hemorrhage is rare. Operative treatment for intraperitoneal rupture is imperative and should be instant. The surgeon opens the abdomen in the median line, tips the patient into the Trendelenburg position, packs back the 1 See important essay on this subject by Daniel Fiske Jones, Intraperitoneal Rupture of the Bladder, Ann. Surg., February, 1903. 410 GENITO-URINARY ORGANS intestines, finds the rent in the bladder, and sews it up. That placing of the sutures is important. Fine catgut is the best material, and a con- tinuous suture here is superior to the interrupted suture, the catgut being so buried in the bladder-wall as to obviate the probability of stone formation. There should be three rows of stitches — the first to include the mucosa, submucosa, and muscularis, the second and third to repair the peritoneal rent and to turn in the line of incision. The abdominal wound should be closed with gauze drainage (stab-wound), and an inlying catheter should be left in the urethra. If symptoms of peri- tonitis exist or appear later, I institute the method of rectal injections described in Chapter VIII (proctoclysis) . Extraperitoneal rupture of the bladder is found in the region of the bladder base, and is due commonly to a direct crushing force which often fractures the pelvis and urethra. These injuries are dangerous also, but less fatal than the intraperitoneal ruptures. The shock is less profound, though hemorrhage may be considerable, while peritonitis is improbable. Blood finds its way behind the peritoneum, both up- ward and backward, distending with hematoma the perineum and the abdominal wall. If untreated, this blood deposit, mingled with urine, becomes septic, and extensive abscesses ensue. In such a case recently, when in doubt as to the exact site of the rupture, I opened into a great bloody cloaca near the navel, and not until I had cleared this out and found the source of bleeding was I able to determine that the peri- toneal cavity was uninvolved. As a rule, therefore, these subcutaneous collections of blood indicate extraperitoneal rupture, intraperitoneal rupture affording exit for blood and urine directly into the peritoneal cavity. In making the diagnosis of ruptured bladder a most valuable aid, and one resorted to as a routine, is catheterization. If rupture exists, especially if an hour or more has passed since the patient urinated, the catheter will draw nothing but a little pure blood, showing that the con- tents of the bladder have escaped inward. Bloody urine in any consider- able amount suggests an injury to the kidneys, or possibly a mere con- tusion of the bladder, while clear urine proves the urinaiy apparatus to be undamaged. The treatment of extraperitoneal rupture of the bladder may be simple or may be intricate. Catheter drainage by the urethra should be in- stituted, hematomata should be opened and explored, hemorrhage should be checked, and, if possible, the bladder rent should be repaired. But such primary repair rarely is possible. Generally, one can do no more at the first than evacuate the bloody collections and drain per- manently the bladder, waiting for nature to act either in establishing a cure or in forming a urinary fistula, which later must be treated by excision and suture. At the same time damaged pelvic bones must be held firmly in place with a plaster swathe. Gunshot wound is a rare injury to the bladder. When the peri- toneal cavity is opened by a bullet, there result sj^mptoms similar to those already described as due to ruptured bladder, and median abdomi- ANATOMY OF THE PROSTATE 411 nal section is necessary. If the wound be extraperitoneal, the condition is not so grave, especially since the track of the bullet affords some degree of drainage for the urine. Otherwise the treatmerit is much the same as in the case of rupture of the bladder. Foreign bodies in the bladder are strangely frequent, and are found in women especially. The significance of foreign bodies in the bladder is that they act as calculi, and generally become nuclei for stone forma- tion. Sexual perverts find strange instruments to use in assaulting their own bladders. Sometimes women introduce foreign bodies into their bladders when attempting to produce abortion, for the large female urethra gives a ready access to the bladder. Hospital museums show curious collections of these foreign bodies removed from the bladders of both sexes — hat-pins, hair-pins, shoe-strings, coins, thimbles, wire- nails, and so on in great variety. They may be removed with forceps and endoscope, by litholapaxy, or by suprapubic cystotomy. Thus it will be seen that the bladder is an organ subject to a variety of diseases, intimately associated in its disease processes with the kidney and ureter, and fairly accessible to instrumentation. It will now be in- teresting to study the common diseases of that important appendage to the bladder — The Prostate General interest in the surgery of the prostate is in marked contrast to interest in bladder surgery, if one may judge from a perusal of current literature. I find in my files of the last four years 48 essays on prostatic surgery as compared with 6 essays on bladder surgery. But, doubtless, with the settlement of debated questions, such a discrepancy will disappear. Although surgeons for many years have done some little work on prostatic disease, it is within the past six or eight years only that reasonably safe and sure relief for prostatic enlargement has been found through the development of an ingenious and rational operative technic.^ The hypertrophied prostate especially has exercised surgeons, but there are other prostatic lesions of great, though minor, interest, and as a preliminary to a brief study of prostatic disease let us, in a few words, consider the anatomy of the prostate. ANATOMY OF THE PROSTATE Observe that the prostate gland lies entirely outside of the bladder and that it envelops the urethra. It does not lie below the urethra, as many students think. The urethra passes through the prostate. The prostate develops in the same manner as do other acinous glands, and grows laterally as well as in the median line. So we find formed two main lateral lobes, between which the urethra passes. The lobes are connected in front of the urethra by the anterior commissure, and beneath the urethra by the posterior commissure. The lower portion of the anterior commissure has been commonly and improperly associated 1 F. S. Watson, The Operative Treatment of the Hypertrophied Prostate, Ann. Surg., June, 1904. 412 GENITO-URIXARY ORGANS with the term, " middle lobe." The glandular tissue is intenvoven with muscle tissue, the muscle tissue being arranged specially about the neck of the bladder, forming an internal and external sphincter, while the 20 or 30 glandular lobules are held together by stout bands of intenvoven fibrous tissue and muscle-fibers, which make up the capsule also. Thus we have entering into the structure of the prostate three distinct types of tissue, ^glandular, fibrous, and muscle, — and as a result we shall find, as we should expect, that these three types enter character- istically into the various forms of prostatic disease. Moreover, there are certain ducts, crypts, and other structures associated with the pros- tate. The ejaculatory ducts pass through it, and it contains its own prostatic ducts, as well as the urethral canal. The gland is compared in size and shape with an Italian chestnvit, its base lying against the bladder and rectum, its apex pointing fonvard under the pubes. If 3'ou split open the prostate from above down into the urethra, you expose certain delicate and interesting structures on the floor of the urethra — the prostatic sinuses or gutters on either side of the verumontanum, and the sinus pocularis or blind canal, tunneling beneath the verumontanum; while upon or within its margins are the slit-like openings of the ejacu- latory ducts. Though the prostate lies entirely behind the triangular ligament, its strongest attachments are to the posterior surface of that ligament, and it is quite firmly bound to the rectum also. The prostate is adherent to the deeper parts of the prostatic urethra, behind the veru- montanum, and this fact explains the difficulty of removing the whole prostate without removing a considerable portion of the prostatic urethra. Furthermore, the whole gland is enveloped in a stout capsule, which is smooth over the lateral lobes, but is intimately connected with the gland in the median line, about the numerous vessels which are located there. The seminal vesicles lie entirely behind the prostate on the bladder-wall. Their ducts enter the prostate from below and pass through it together, close to the median line, until they empty into the urethra. On this anatomic fact Young ^ has founded his proposition of removing prostatic lobes through lateral incisions into the gland, so as to avoid injuring the vessels and the ejaculatory ducts. So much for the anatomy of this organ, which has been abundantly studied and copiously illustrated by recent writers. We may conveniently group diseases of the prostate under the headings inflammations, hypertrcphy , and tumors, though it may be proper to regard hypertrophies as either inflammations or tumors. INFLAMMATIONS OF THE PROSTATE Inflammations of the prostate are acute and chronic, but we usually mean acute inflammation when we speak of prostatic inflammation. Acute inflammation of the prostate assumes the forms common to all glandular inflammations. Ordinarily in acute prostatitis there is an invasion by organisms of the ducts from without — from the urethra. 1 Hugh H. Young, Jour. Amer. Med. Assoc, October 24, 1903. INFLAMMATION OF THE PROSTATE 413 Swelling, desquamation, necrosis, and suppuration supervene, the usual attendant efforts of nature to arrest the invasion. The gonococ- cus and other pus-producing cocci are the ordinary invading organisms, while rarely the organisms of tuberculosis and syphilis may be implanted here. The patient experiences a sense of weight, heat, and pain in the perineum. Often there are frequency of micturition and tenesmus from involvement of the bladder. There may be great prostration and a general constitutional disturbance. Frequently the onset of the attack comes with a chill. The abscess may open into the urethra, rectum, or bladder, or into the peritoneal cavity even, through burrowing upward. Either the parenchyma of the prostate or the muscular tissue or both may be involved. Sometimes there is urinary obstruction, and in extreme cases the process may go on to destruction of neighboring Fig. 247. — Massaging the prostate. Sketch showing position of hand and forearm. Fig. 248. — Sketch showing relative posi- tion of surgeon and patient. parts through gangrene, to peritonitis, phlebitis, thrombosis, and py- emia. Occasionally acute symptoms gradually may subside, leaving behind a chronic process which is marked by a general thickening and enlargement of the prostate, associated with a cord-like thickening of the vesicles and ducts, and in some cases by a well-defined abscess. The most important symptom of chronic prostatitis is a discharge from the urethra of a milky fluid, in greater or less quantity, especially after defecation, followed by pain in the course of the urethra. The reader will probably conclude that the treatment of prostatitis varies with varying forms of the disease. In acute prostatitis one en- joins absolute rest, thorough evacuation of the bowels, urotropin, and the application of either heat or cold to the perineum and hypogastrium. Sometimes constant cold rectal irrigations are a great comfort. If an abscess develops, it must be opened, preferably through the perineum 414 OENITO-URINARY ORGANS or urethra. If the prostatitis is gonorrheal, local urethral treatment must be abandoned temporarily or until the prostatic complication sub- sides. Burrowing pus and complicating infections must be treated by appropriate dissections. Chronic prostatitis is a difficult subject for treatment. It yields slowly, if at all, though sundry well-recognized remedies should be used and may be helpful. If gonorrhea or stricture is present, it must be cured, because it may be keeping up the prostatic irritation. Cold applications by rectal irrigation are com- forting, lodin in some form is valuable, and may be applied by m- unction to the perineum, or, mixed with an ointment, it may be passed on a sound into the deep urethra. Most important of all, prostatic massage is extremely helpful. The seminal vesicles fre- quently are involved with the prostate, and massage of all these organs, by the finger in the rectum, should be practised for a time, at intervals of every third day. Frequently it is surprising to feel the in- duration subside under the finger, while the patient will return after the first or second treatment with the statement that he is greatly relieved. Certain enthusiasts have claimed great benefit from opening the vesicles and prostate through the rectum or through the perineum, but the ex- perience of others suggests that this is a difficult remedy, and may be dangerous. The value of prostatectomy for chronic prostatitis is still sub judice. Patients afflicted with infiammatoiy prostatic troubles are apt to become wretched '' neurasthenics," as the phrase is, and their general health should be looked to carefully, with tonics, mineral baths, and sanatorium treatment. Tuberculous prostatitis usually is secondary, almost never primary, and its treatment should be symptomatic, as a rule — an out-of-doors life. If an abscess has formed, it may be opened, and the prostate cur- etted or enucleated through a perineal incision without opening the rectum. Unfortunately, these cases, as a rule, go on to a general tuber- culosis. PROSTATIC CALCULI Prostatic calculi deserve mention, though they are relatively rare and may well be confounded with bladder calculi. They are generally phosphatic, and may be multiple, collecting in the prostatic sinuses. The symptoms simulate closely those of stone in the bladder, and the positive diagnosis often is difficult. Prostatic stones may be detected protruding into the urethra, by the examining finger in the rectum, w^hile a sound in the urethra supports the prostate. Those calculi which protrude into the urethra may be picked out with long urethral for- ceps, while the larger and more deeply placed stones can be extracted by perineal section. These prostatic calculi, like gall-stones, are to be regarded as of inflammatory origin, their nuclei being generally the desquamated cells resulting from some previous infection. By far the most interesting disease of the prostate, however, and one which many are coming to believe represents in an extreme degree the results of long-standing inflammation, is hypertrophy of the prostate. HYPERTROPHY OF THE PROSTATE 415 HYPERTROPHY OF THE PROSTATE Benign enlargement of the prostate is commonly called hypertro'phy of the prostate, .-^.bout this disease debate still centers. What is its cause? How shall it be treated? Briefly, let us consider these questions, as well as the questions of symptoms and diagnosis. Statistics seem to show that 30 per cent, of men over fifty have some degree of enlargement of the prostate. Fortunately, as in the case of gall-stone victims, the lesion produces serious symptoms in a relatively small proportion of persons. It is rare to hear of prostatic disturbances in a man under forty-five, and it is still rarer that the initial symptoms of enlarged prostate appear after seventy. There is excellent reason for believing, however, that frequently the prostatic disease begins much earlier than the forty-fifth year. The question of etiology has given rise to an interesting discussion, as yet unsettled, but the studies of Finger, Ciechanowski, Crandon,^ and others are so thorough, and their findings so convincing, that I believe we are justified in concluding a majority of these enlarged prostates to be of inflammatory origin. Crandon draws the following conclusions: " (1) The underlying cause of the usual form of prostatic enlargement and of certain forms of prostatic atrophy is a slow formation of new con- nective tissue, due to infection or to infection aggravating a senile degen- erative process. " (2) The gonococcus is probably most often the specific infection (?) because^ (a) of its great frequency; (6) other inflammatory^ causes are not common in the parts in question; (c) a great similarity exists be- tween the histology of gonorrheal processes and those seen in these senile prostates. " (3) Neoplasms, fibromyomata, and adenoma occur, but may be called rare." Numerous other writers, from Morgagni and John Hunter do\\Ti to those of our o-^ti time, have held varying views of the etiology, assert- ing that these enlargements are due to inflammations, to new-growths, to some relation betw^een the testes and the prostate, to a general h^-per- trophy of prostatic connective tissue, etc. ; but it now seems probable, as I have already stated, that a chronic inflammation of the glandular elements is the most important element in the etiology of prostatic hypertrophy. Doubtless, myomata and other new-growths occasion- ally play a part, while Young finds that prostatic cancer is found in about 14 per cent, of those persons who come under surgical treatment for prostatic enlargements. The size and the shape of enlarged prostates vary, though the largest prostate is not likely to be more than four or five ounces in weight. The enlarged prostate may be spongy, or may increase in consistencj' up to a hard fibrous resistance, and there may be variation also of consist- ency in different parts of the gland. One lateral lobe only may be en- 1 L. R. G. Crandon, The Pathogenesis and Pathologic Anatomy of Enlarged Prostate, Ann. Surg., December, 1902. For an interesting resume of opposing views see article by Paul Si. Pilcher, Ann. Surg., 1905. 41G GENITO-URINAKY ORGANS largcd, or there may occur the formation of a middle lobe. This last is an interesting condition. Formerly it was held that the middle lobe arises from the posterior portion of the isthmus, but later and more care- ful observations demonstrate that the poly})oid middle lobe has nothing to do with the isthmus. The middle lobe tlevclops from a few, isolated, prostatic acini, which lie between the vesical nmcosa and the internal urethral sphincter. The middle lobe alone may be enlarged or it may be associated with enlargement of the other lobes. The most common form of enlargement is the bilateral form, and after that a uniform enlargement of the whole gland, including the middle lol)e. The student will observe, therefore, that enlargement of the prostate may or may not give rise to distortion or obstruction of the urethra, Fig. 249. — Suprapubic prostatectomy. Sagittal section of pelvis, show-ing finger enucleating the prostate from its sheath as counterpressure is made i)y the other hand in the rectum Shows also tortuous course of urethra througli enlarged prostate. according as the forms of the enlargement vary. An overdevelop- ment of one lobe will push the urethra to one side; an overdevelop- ment of both lobes will elongate the prostatic urethra. An upward protrusion of the prostate into the bladder will elevate and throw for- ward the internal urethral orifice, or there may result an actual bar formation at the neck of the bladder. The reader will observe also that the enlarged prostate may project as a whole beneath the bladder mucosa, rendering the tumor easily accessible from above; or the growth may project toward the rectum only, rendering the mass easily accessible from below. All these variations in size and shape may puzzle the stu- dent, but he should study the formations on the cadaver and in plates. The syynptoms of enlarged prostate should be obvious to the reader who is familiar with diseases of the bladder, for the prostate, when en- HYPERTROPHY OF THE PROSTATE 417 largcd, becomes essentially a tumor of the bladder-wall, while necessarily it involves the urethra at the same time. Therefore, the first and most characteristic symptom of enlarged prostate is J'requcncy of micturition; and note this characteristic fact, that the frequency is most pronounced at night, and is due to a congestion of the bladder and prostate. Next the patient notices difficulty in passing water, so that the act is accomp- lished with straining and more or less pain. The difficulty increases with time, until the flow comes drop by drop. This difficulty is due to the tortuous course into which the urethra has been forced by the enlarging prostate, and to the consequent elevation of the internal Fig. 250. — General prostatic enlargement with the formation of a median over- growth and posterior pocket or sac. Illustrating how residual urine may be retained, as well as the difficulties of all kinds of instrumentation (Socin and Burck- hardt). meatus toward the front of the bladder-wall, where a valve-like opening is formed, which excessive straining closes. As the enlarged prostate encroaches upon the urethra within it, it throws the lower posterior part of the bladder into a cup-like fold, depressed beneath and behind the internal meatus. As a result, urine which cannot be evacuated collects in this pocket — so-called '' residual urine," that which remains after the patient has evacuated all that he can (Fig. 250). With such con- ditions present one maj^ easily picture the complications and results of prostatic enlargement. An underlying gonorrhea, exposure to cold and wet, some slight injury, or some intercurrent illness may be the 27 418 GEXITO-UKIXARY ORGANS immediate cause of an acute infection, when there follow increased swelling of the gland, invasion of the bladder by septic organisms, cystitis with decomposition of the residual urine, increased frequency, pain, and further wretchedness. The progress of prostatic hypertrophy so called is by no means uni- form. A majority of the victims of prostatic hypertrophy live for many years wdth but slight difficulty. Their troubles are not constant, for their attacks come and go with varying frequency. Generally, they can be kept comfortable with care in the diet, regulation of the bowels, and a more or less quiet life. On the other hand, certain cases progress rapidly to complications. The prostate enlarges, the obstruction be- comes more pronounced, inflammation is quite constant, residual urine increases in amount, the bladder becomes chronically inflamed, thick- ened, and sacculated, and finally the infection extends to the ureters and kidneys, so that the patient succumbs eventually to a pronounced general infection. Many of the patients are sufferers from arteriosclero- sis and heart complications; their condition is anything but favorable, either for prolonged life or for operation. One cannot lay down definite rules of treatment ; each case must be handled on its own merits; for some, an early operation may seem best; for others, palliative treatment, in the hope that an operation msiy be avoided. Palliative treatment is extremely serviceable, and consists in the proper use of the catheter. The surgeon, so soon as he is convinced that " frequency" exists and that it is associated with more or less pain, should pass a soft catheter into the bladder and determine whether or not there be residual urine present. Usually, he will find it there, and if so, he should instruct the patient to empty the bladder with the catheter frequently enough to secure comfort. Some patients require catheteri- zation but once a day, preferably in the evening. Others should catheter- ize themselves twice a day, others more often; but I doubt if it is wise ever to encourage a patient to use a catheter more than five or six times in the twenty-four hours. The type of catheter to be used is all important. If the disease be not pronounced, if the prostate be small, and the passage fairly patent, the patient may use a No. 10 or 12 EngHsh soft-rubber catheter, which will easily enter the bladder. My preference is to limit patients to this type of catheter. I never feel safe in allowing them the use of stiff or sharply curved instruments, so that I have formulated this rule: if the patient can pass comfortably and safely a soft-rubber catheter, I allow him to do so, but no more than four times in the twenty-four hours. If more frequent catheterization is necessary, I take the matter out of the patient's hands and catheterize him myself, or advise a rad- ical operation. The question of what catheter the surgeon himself shall use to enter the patient's bladder has provoked needless discus- sion: if I cannot pass the soft-rubber catheter, then my preference is for the gum-elastic English web. No. 10 or 12, armed with a stilet. When this is properly curved in an S shape, it may generally be passed into the bladder without difficulty. Hey's old maneuver of HYPERTROPHV OF THE I'KO.STATE 419 passing it as far as possible, and then withdrawing the stilct about an inch so as to allow the beak of the catheter to jump forward and upward, is extremely useful still. There are the familiar instruments with curved angles, those of Mercier, of LeRoy, and of Guthrie. In an emergency, if the patient's bladder is full, if the catheter cannot be passed, and if relief must be secured at once, the bladder may be aspirated above the pubes— an easy operation and painless if a little 2 per cent, cocain has been injected under the skin previously. In the use of catheters absolute cleanliness must be secured, and the utmost gentleness must be employed. In these patients the prostatic urethra is twisted and occasionally sacculated, so that any considerable force may cause the beak of the cath- eter to pass into the prostate gland itself. False passages thus are formed, which become infected, and the misery of the patient shortly becomes ex- treme. If catheterization is impossible, if aspiration above the pubes alone re- mains, and if operation is contraindi- cated by the poor general condition of the patient, constant drainage above the pubes may be secured by leav- ing the cannula of the aspirator in place. After a few days the cannula may be withdrawn and a small cath- eter inserted. This drainage, which has been established with little or no shock to the patient, acts kindly upon an inflamed prostate, relieving it of pressure, subduing congestion, and frequently bringing about the state of affairs which permits of the subsequent passage of a catheter by the natural route. If the patient's strength remains good, but the reestablishment of urethral drainage is impossible, and a radical operation is too dangerous, it may seem well to the surgeon to establish permanently suprapubic drainage. This can be done with slight shock to the patient, and is a relatively easy operation. (It is accompHshed essentially by the method I described when speaking of stone in the bladder — by suprapubic cystotomy or, in this case, cystostomy.) The bladder is brought up into the external wound, its wall is opened, and the catheter is inserted by the Witzel method or by that of Gibson. The catheter may be worn permanently, or may be withdrawn after ten days and the resulting sinus may be utilized for the passage of urine. A fairly competent stoma frequently results, so that the patient can retain a considerable amount of urine in the bladder, and then, by straining or pressing above the pubes, can empty the bladder without a catheter. The reader should not be confused, however, or led to suppose that this is a common outcome of the catheter life. Permanent drainage by suprapubic cystostomy rarely is necessary. Fig. 251. — Diagram showing cath- eter placed for bladder drainage. 420 GENITO-l'IMNARY ORGANS Let US now briefly consider methods of dealing directly with the gland itself — removing it or tunneling a pro))er passage through it. The prostate may b(; drilled through by the instrument of Jiottini, or may be removed entire, either fiom above (su])ra])ubic prostatectomy) or from below (perineal j^rostatectomy). That operation of liottini is interesting; first developed by him in 1S74, its technic has been greatly improved, especially by the author himself and by Freudenberg and Young, until the best modern instruments have assunujd a form of efficiency which renders them accurate and effective. General anes- thesia is not necessary for their use. The operation is frequently per- formed with the employment of cocain anesthesia only. Persons un- familiar with the Bottini operation have claimed that it is blind, un- surgical, and dangerous; but the elaborate statistics of Watson and others show that the Bottini operation, in proper hands, is effective, and carries with it a low mortality. In a word, the instrument is a galvano- cautery which burns deep grooves in the projecting prostatic lobes, and opens a free passage for the urine. Before employing this instru- ment it is imperative that the surgeon inspect the prostate and the bladder with the cystoscope. Without such visual inspection one cannot determine the relations of the enlarged prostatic lobes to each other and to the urethra, but, instructed by the cystoscopic inspection, the surgeon should be able accurately and deftly to burn the required tunnel. Young's improved instrument generally is used in this country. Its advantage is that it has a variety of blades enabling the surgeon to enlarge the oj^ening required to any desired extent. Disinfect the urine with urotropin and one or two vesical irrigations. No other sub- sequent treatment is necessary. These patients have been allowed to go about after forty-eight hours even, but such radical haste is not to be commended. The patients generally are persons of advanced years, with an enfeebled cardiovascular system, and should be kept quiet until the immediate ill-effects of the operation have subsided. Enjoin hot sitz-baths, a milk diet, diuretics, rest, and fresh air. In spite of the advantages of Bottini's operation, I cannot agree with those writers who assert that it is always the operation of choice. On the contrary, I believe that it is often the operation of last resort, and is to be employed in those cases only which cannot be submitted to the more radical operation of prostatectomy. In general terms, then, the surgeon should reserve the Bottini operation for those patients who are so enfeebled that one dare not inflict upon them a prostatec- tomy. The immediate results of the Bottini operation generally are good, but the end-results are not always satisfactory, for recurrence of the urethral obstruction not infrequently follows after an interval of one or two years. Complete 'prostatectomy or radical proslatcctortiy is a subject which agi- tates operators to-day, and it has done so for the past ten years. \'ig- orous exponents of the suprapubic and of the perineal routes are still in conflict. It is not reasonable that such conflicts should continue. Any surgeon familiar with both operations will admit that each has its place. HYPERTROPHY OF THE PROSTATE 421 Those enlarged prostates which encroach Uttle upon the rectum and perineum, but project far into the interior of the bladder, are more easily attacked from above by the average operator, so that for those cases I advocate the suprapubic operation except for the expert. It can be done readily, satisfactorily, and effectively, and the results are almost always good. On the other hand, those prostates which encroach upon the rectum and lie almost entirely in front of the bladder are prop- erly and easily to be removed by the perineal route. The statistics of "both operations vary, and the weight of evidence seems to show that the suprapubic operation is somewhat the more dangerous, having a Fi„ 252.— Diaerammatic drawing, showng above, a flap of mucous membrane left by^'shelling out a prominent third lobe, and below, a remnant ot the urethral mucous membrane extending back into the cavity frorn which the prostate has been removed— either of which would tend to form a valvular closure ot the urethra (Cabot). rather higher operative mortality rate. One questions w^hether this may not be because surgeons have failed to choose their method judi- ciously, but have employed the suprapubic route for cases which should have been operated upon by the perineal route. Suprapubic prostatectonnj is an easy operation, as a mie. ine bladder should be fiUed wdth 4 to 6 ounces of boric-acid solution; the patient should be placed in a mocUfied Trendelenburg position, and the surcreon should approach the bladder through a transverse, longitudinal or crescentic incision above the pubes. Then, ha^^ng seized the walls of the bladder, he should open it by dissecting, when, with a finger in the rectum elevating the prostate, that gland is brought immediately 422 GENITO-IIUNARY OHCiANS into touch with a finger entering the bhiddcr from above. The surgeon then incises the mucosa over the tumor. It is now an (uisy matter to shell out the enlarged gland, which brings with it, usually, a portion of the prostatic urethra. Much has been said on the question of remov- ing the prostatic urethra, but the best evidence shows that it is impos- sible to perform su]n-a]iubic prostatectomy without damaging the urethra. The after-history of these cases is so good, however, that many surgeons have come to feel such damage to the ui'cthra to be by no means permanent — indeed, to be negligible. The advantages of suprapubic enucleation are that the operation is done through a wide incision, that the danger to the rectum and membranous urethra is Fi Hemostatic bulb and tube in place (J. 1' is). slight, and that the whole maneuver can be performed quickly. Hem- orrhage generally is inconsiderable. If the hemorrhage does not cease shortly with copious irrigation, one may well employ the hemostatic tube or bulb devised by J. E. Briggs, and shown in the accompanying cuts.^ After the removal of the prostate, thorough drainage should be established and continued for at least ten days. My custom is to place an inlying catheter in the urethra, and to sew a drainage catheter into the bladder from above. I prefer to bring out the suprapubic drainage through the middle of the superior skin-flap, leading out with it at the same time a gauze wick which shall drain the prevesical space. The 1 J. Emmons Briggs, New England Med. Gaz., April, 1906. HYPERTUOrHY OF THE PROSTATE 423 v/ick should be removed after four days, but the drainage catheter should be left for several days longer. Fretiuentl}' in the case of feel)le old men I have established prelim- inary drainage of the bladder through suprapubic cystostomy. At the end of a week, or ten days often, it is observed that the patient's general condition has improved greatly; renal function has been improved, and the heart action is better than before. One may now proceed with enucleation of the prostate through the already opened supra- pubic wound, or, if it seems best, one may perform perineal prostatectomy. Occasionally, it appears that the patient is too feeble to bear the secondary operation, in which case long-continued drainage above the pubes relieves congestion, eliminates cystitis, encourages shrinking of the enlarged pros- tate, and allows the patient, if necessary, to return to the catheter life. The suprapubic operation has found its greatest favor among English and Indian surgeons, whose experience in this method has been large. Es- pecially of recent years has the technic been im- proved, and has become associated with the name of Freyer, whose vigorous advocacy of a rather an- cient practice has brought him into prominence before the surgical public.^ Among American surgeons, however, the opera- tion of 'perineal prostatectomy is the favorite. Numer- ous modifications of this operation have been de- vised. Indeed, it seems sometimes as though there were as many modifications as there are operators — so that I must content myself with describing what I believe and have found to be a satisfactory operation; essentially it is that of Young.- Be- fore undertaking the operation of perineal pros- tatectomy the surgeon should have clearly in mind answers to the following five propositions : method of approach to the prostate; method of exposing the tumor; method of enucleation; preservation of the urethra and ejaculatory ducts; treatment of the wound. The position for the patient is the exaggerated lithotomy position, which can best be secured by tipping up the Trendelenburg table. I em- ploy the inverted V incision of Young (Fig. 255) ; rarely the simple median incision advocated by Samuel Alexander, and then in the case of thin pa- tients only. On turning down the skin-flap the superficial muscles are 1 There have been humors even of this controversy. F. S. Watson recently al- luded to the conspicuous advocate of suprapubic prostatectomy as "the universal usurper of previously preempted prostatic privileges." 2 Hugh H. Young, Conservative Perineal Prostatectomy, Jour. Amer. Med. Assoc, October 24, 1903, and February 4, 1905. Fig. 254. — Diagram of hemostatic tube. 424 GEXITO-URIXAKY ORGAXS exposed. There are now but two structures to cut in order to expose the nienibranous urethra and the prostate. The first structure is the central tendon of the perineum (Fig. 256), which passes fonvard and is in- serted into the bulb of the urethra. Cut this, and by the same maneuver free the sphincter an! and the levator ani from their anteiior attachments. This loosens the rectum also, though it is still held by the recto-urethralis muscle, Avhich comes immediately into view. One must divide now this muscle, for it is the structure which holds forward the rectum. By its division that organ is allowed to fall back out of the way of further dissection. The division of the recto-urethralis and further blunt dis- Fig. 255. — Perineal prostatectomy step 1 (redrawn after Young). Fig. 25fi. — Perineal prostatectomy — step 2. Exposure of central tendon by bifid retractor (redrawn after Young). section, with proper retraction, reveal the membranous urethra and the anterior portion of the prostate gland. At this point a grooved staff may be passed into the urethra, or the staff maj' have been inserted before beginning the operation. Open the membranous urethra u]:)on the staff. The approach to the field of operation is now complete. In order to bring the tumor into proper view, use as a routine the well- known tractor of Young. One opens the membranous urethra, with- draws the staff, and passes the tractor into the bladder thi'ough the membranous and prostatic urethra. One then opens the blades, which nvri:irn{orHY of the riiosTATio 425 arc nuule to lie across the lobes of the prostate. Then with gentle firm traction, draw the prostate well clown into the fieltl. A'ext incise the two lateral lobes separately. Having opened down through the capsule, dissect out the lobes with a blunt dissector, seize them with forceps (Fig. 258), and drag them out until they hang by their prostatic attachments. At this point introduce a finger into the wound so as to make sure of not tearing through into the urethra or bladder. Then cut away with scissors the prostatic attachments of the lobe, and repeat the operation on the other side. In this way the urethra, the ducts, and the bladder itself may nearly always be spared serious damage. Fig. 257. — Perineal prostatectomy — step 3. Opening the urethra on sound preparatory to introduction of tractor (redrawn after Young). Fig. 258 — Perineal prostatectomy — step 4. Enucleation of lobes, forceps in position (redrawn after Young). If there be but a small middle lobe, it may be forced down into one of the cavities left by the removal of the lateral lobe, and it maj- be seized and extracted in much the same manner as w^as the lateral lobe (Fig. 259). Sometimes there is a large middle lobe which cannot easily be managed by the tractor. In such a case enlarge the opening in the urethra, pass the finger into the bladder through the prostatic urethra, and thus easily bring down the middle lobe to within reach for extraction. Then, with the finger in the bladder, search thoroughly that organ for further ab- normalities— sacculations and calcuH, though such conditions should have been demonstrated previously by the cystoscope. The dressing of the wound is a simple matter. Thorough drainage of the bladder 42G GEXITO-UIIIXARY ORGANS must be instituted. For this })urpose it is Ix'st to use a large drainage- tube and a small catheter, sewed together side by side, and introduced through the membranous urethra into the bladder. By the use of tliis instrument the bladder can readily be washed out. Then pack hghtly the cavities with gauze wicks brought out at the lower angles of the V- shaped wound, the double drainage-tube being led through the middle of the flap. The cut muscles of the pei-ineum may be restored with cat- gut stitches; the skin wound is then sewed up with interrupted silkworm- gut stitches. Of the numerous modifications and changes in the technic, I have employed on three occasions the method of Ferg-uson, who passes "-C. n \ J ^-J \v- ' > ' 1 1/ i i J k h \ Fig. 259. — Perineal prostatectomy — step 5. Delivery of middle lobe into cavity of left lateral lobe (redrawn after Young) . Fig. 260. — Perineal prostatectomy- step 6 (redrawn after Young). a soft-rubber catheter through tbe urethral meatus for drainage, and so into the bladder. In closing he sews up the wound in the mem- branous urethra. Although this is an excellent maneuver in most cases, I found in one of my cases that it did not comfortably drain the bladder, and I have returned to the method described by Young — the double drainage-tube leading out through the perineum. If all goes well, the subsequent history of these cases is uneventful. Remove the drainage-tube on the third day, and the gauze packing on the fifth day. There is often more or less perineal leakage, but gener- ally the healing is sound. It sometimes happens that infection of the HYPERTROPHY OF THE PROSTATE 427 wound or a persistent cystitis makes necessary frequent irrigation of the bladder. Or it may be that the drainage is unsatisfactory. Under such circumstances I have used with advantage the apparatus devised by A. J. A. Hamilton, and employed first at the Carney Hospital in Boston^ (Fig. 261) . By the end of three; or four weeks the patient should be pass- mg his urine by the natural channel. 1 like to get these patients up as early as possible, and fre- quently have them sitting up ^ — f k^ erati()n of extreme difficulty. An assistant must hold the staff in the urethra so that the staff bulges the i)enneum. The surgeon then cuts down upon it, opens the urethra, and secures its edges with retention stitches. Usually there is a good deal of bleeding, which obscures the field if the hemorrhage be not controlled. The surgeon next endeavors to discover the uninjured proximal end of the urethra. This may necessitate a tedious and extensive dissection. If the scar tissue be insignificant in extent, it may be cut away, the proximal urethral stump discovered, and an end-to-end urethral junction estab- lished. The difficulty is to find the proximal end. There are a number of maneuvers in technic which help to accomplish this purpose. One is to discover and identify an important artery — a branch of the artery of the bulb, which runs forward along the course of the urethra and close to that canal. If one can isolate this artery, one may be sure that he is in close proximity to the sovight-for urethra. Again, the elusive urethra may be discovered by forcing urine through it from the bladder, by pressure on the bladder above the pubes. To this end the surgeon should instruct the patient not to empty his bladder before the operation. Often no special difficulty is encountered, and almost at once, on opening the perineum, the surgeon finds the urethra and passes a probe, director, or Teale's gorget through it into the bladder. When once you have isolated the proximal portion of the urethra, do not lose it. The fur- ther treatment of the stricture is not especially difficult. If the two portions of the urethra can be brought together and sutured, the prob- lem is solved at once. If this cannot be done, the surgeon should pass a large catheter or drainage-tube through the perineal wound into the bladder, and fasten it there for temporary drainage. At the end of five or six days, when granulations have begun to appear, the drainage catheter should be removed, and sounds of a proper size should be passed every other day through the penile urethra and into the bladder. The success of this maneuver in reestablishing the normal passage de- pends upon the fact that the urethral mucosa has a curious capacity for bridging space, as we see illustrated in the restoration of the urethra after it has been torn out in the operation of suprapubic prostatectomy. As a rule, the convalescence from perineal section is eas}^ and sur- prisingly short. The perineal fistula closes in two or three weeks, and the urethra soon takes up its proper function. It is well to pass a sound occasionally, perhaps once or twice a month, for several months after the operation, in order to provide against recontraction of the canal. In some rare cases a permanent cure is not established, owing to the wide damage caused by the original traumatism. In such cases the patient's comfort through the rest of his life will depend upon the occasional passage of a sound. Acquired stricture, the result of gonorrhea, may be inflammatory and temporary in exceptional cases, but is usually due to permanent tissue changes — organic stricture. There is also the spasmodic stric- ture, the result of a contraction of the circular muscle-fibers of the STRICTURE OF THE URETHRA 455 urethra or of the compressor urethrae. This spasmodic stricture is a reflex affair conmionly. It may be a neurosis; it maybe due to terror, anxiety, or embarrassment, or it may be due to posture, such as lying on the back. I have already discussed it when speaking of diseases of the female genital organs. Analogous conditions exist in the male. Usually the spasm may be relaxed by hot applications over the bladder and on the perineum, by immersion in a warm bath, often by the sound of trickling water; if necessary, by the use of small doses of opium, pref- erably in suppository form (powdered opium, 1 grain), and if these measures fail, by the catheter. Inflammatory stricture is a rare condition, and some authorities have doubted its existence, attributing the state to a previously existing organic stricture. I have convinced myself, however, from experience with a variety of cases, that inflammatory stricture, a swelling of the urethral mucosa, may sometimes exist so as to cause narrowing of the stream or its complete obstruption even without relation to organic stricture. The obstruction of inflammatory stricture may be easily overcome by immersion in the warm bath, or if that does not succeed, by a small soft-rubber catheter. Organic stricture from gonorrhea is the condition with which we are concerned here; and organic stricture of gonorrheal origin is the stricture of daily experience. A long-standing gonorrhea sets up and leaves be- hind it in the mucosa areas of ulceration, or chronic injections and thick- enings of the mucous lining. At the affected points, infective agents penetrate the mucosa and involve the para-urethral structures. Har- rison has said that urine actually penetrates through the mucosa, but this is not necessary for the establishment of an inflammatory exudate. This exudate encroaches from without upon the lumen of the urethra and causes narrowing of that canal. In process of time cicatricial tissue takes the place of the exudate, with a resulting permanent contraction of the urethra — by cicatricial tissue which may or may not involve the urethral canal itself. The reader will perceive, therefore, that the extent and nature of the stricture may vary greatly. There may be the rare, single, encircling stricture; but more commonly the stricture is rather diffuse, and frequently there are multiple strictures. The urethral canal may present a mere, smooth narrowing, or it may be throw into folds and pockets so that the urine must pass in a labyrinthine course. From these conditions the reader will see that the treatment of stricture may be a simple undertaking or may be extremely com- plicated. The symptoms of stricture vary with the character and degree of the contraction. Usually the patient will give a history running back over about two years. He tells of frequency of micturition and of narrow- ing of the stream, which may be double, flat, or spraj'-like, or may be passed in drops only. In advanced stricture there is diminished ex- pulsive power and dribbling at the end of urination. Occasionally there is scalding. Rarely there is that retention of which I have treated in Chapter XIV. During the act of micturition there is wont to be vesical 456 gp:nito-uri.\auy organs tenesmus. Sometimes there is a constantly present slight urethral discharge of nuicoid material; often the act of coitus is incomplete, and the patient may suiYer from a condition of general debility induced especially by involvement of the bladder and kidneys and an extensive breakdown of the urinary apparatus. In explanation of some of the above symptoms the reader should acquire a further knowledge of the nature of stricture and its sequelaj and of the complicated processes which it sets up. Bearing in mind that the normal urethra is a collapsible, elastic tube, through which urine flows without obstruction, and in which the pressure is everywhere equal during micturition, one perceives that stricture alters this normal condition — stricture of the largest caliber even. \Miencver there is the slightest obstruction to the stream of urine, the pressure in the urethra behind the stricture is raised, and is lowered in front of the stricture, just as one sees the pressure in a common garden-hose affected by constricting the tube ever so slightly with the fingers. In the urethra the effects of the constriction slowly become manifest, and the remote symptoms from which the patient suffers eventually appear to be due to the constant back pressure rather than to the mere trifling inconvenience of emptying the bladder slowly. Behind the stricture the dilatable urethra is distended and may be permanently sacculated even, becoming a reservoir for small amounts of urine which dribble away after the act of micturition has been checked. In this dilated urethra there is encouragement for a process of chronic inflammation, which extends often to the prostatic sinuses, seminal vesicles, and testes. Behind the prostate the bladder is called upon for increased work in order to empty itself against the resistance of the structure; the bladder be- comes hypertrophied and may become sacculated ; later it may become thin-walled, flabby, distended, and incapable of proper contraction; fre((uently it is found to be the seatof a chronic cystitis; and, finally, the irritating process extends to the ureters, renal pelves, and kidneys, until the whole urinary tract is involved in a process of chronic inflam- mation. One sees then that strictures of both large and small caliber are not lightly to be regarded. The treatment of organic stricture of gonorrheal origin is similar to that I have described in discussing traumatic stricture. The con- striction or constrictions must be located. This may be accomplished roughly by palpation of the urethra from without and the determination of abnormal thickenings in its course. For the more accurate ascertain- ing of the location and extent of strictures, bougies or the instrument of Otis suffice. In my opinion the bougie a boule is most useful. Differ- ent sizes of this instrument are used, and as they pass into and beyond the stricture and are withdrawn, they are made to determine the stric- ture's location and caliber. They will fail to detect, however, a stric- ture of large caliber lying behind a stricture of small caliber. To deter- mine this condition the urethrometer of Otis is invaluable. Frequently the surgeon is in doubt as to what constitutes a stricture of large caliber in a given urethra. He may determine this by the proportionate scale STRICTUKE OF THE URETHRA 457 of mensurements of the flaccid penis, which I have already described. Having determined the site and extent of the stricture, the surgeon may cut it or dilate it gradually. In general terms the problem re- solves itself into a consideration of the treatment of penile strictures or of strictures of the bulbomembranous portion. If the stricture be con- fined to the penile }X)rtion, and if an instrument can easily be engaged in it, the stricture can generally be stretched to a proper size by graduated steel sounds. This operation may be done with the aid of cocain anes- FT^ « Fig. 278. — Olivary bougie (Fowler). Fig. 279.— Otis's urethro- meter (Fowler). A Fig. 280.— Dilating urethro- tome of Otis (Fowler). thesia (4 per cent.), the size of the sounds being increased gradually by three or four sizes at each sitting, and the instruments being em- ployed once every five or ten days. By this means, in the course of a month or two, a stricture of moderate dimensions maj^ be cured; but the patient should be instructed to have his urethra searched occasion- ally thereafter in order to anticipate a recontraction of the stricture. If the penile stricture be of small caliber, and if it does not jaeld readih'', it may be cut with the Otis urethrotome, after which the use of sounds 458 GEMTO-UKINARY ORGANS must be continued for several weeks. The use of the urethrotome must be limited to strictures anterior to the bulbomembranous portion. I do not believe that the rapid divulsion of strictures in the penile portion is a proper operation except in the case of soft strictures of large caliber. Strictures of the bulbomembranous urethra may be treated with sounds when the passage of sounds is possible. In a large proportion of cases this treatment is sufficient. In the case of complicated, close, and un- yielding strictures, however, the passage of sounds is impossible, so that under these circumstances the surgeon must resort to the perineal section, as I have already described it. Kapid divulsion of close, hard, deep strictures is not permissible, because rapid divulsion implies vio- lent tearing up of tissue, which may cause serious hemorrhage, and leave the lacerated urethra in a condition which admits of infection and urinary extravasation. So much for the treatment of stricture, one of the most obstinate and troublesome of the sequelse of gonorrhea. Patience and tact, almost superhuman, sometimes are needed for the conduct of these trj'- ing cases. URETHRAL FISTULA Urethral fistula, a sinus between the urethra and the outside world, is a condition due to injurj^ or to the breaking outward of a para- urethral abscess. It results from gonorrhea generally. These fistulse may discharge a part or the whole of the contents of the bladder. Often they lie behind a stricture, which complicates the situation. They cannot be cured by mere cureting or touching with caustic or the cautery, as used to be attempted. The proper treatmeni is to divide them freely fromi without — practical!}' an external urethrotomy, and then to curet them or excise them. At the same time the urethra must be cut or stretched to its proper size. This treatment results usually in a prompt cure. URETHROSCOPY Urethroscopy deserves a word of explanation, for it is the means by which most easily the interior of the urethra is examined. The principle of the urethroscope is similar to that of the female cystoscope (described in Chapter X) . The instrument consists of a hollow steel tube which is passed into the urethra and is used in connection with a head- mirror, which throws a reflected light into its depths; or the direct light of a cold lamp near the distal end of the tube itself may be em- ployed. In this fashion the surgeon inspects the lining of the urethra. He keeps the field clean with swabs of absorbent cotton passed through the tube, and notes such abnormalities as congestion, inflammation, patches of ulceration and cicatrices, and if he choses he makes applica- tions directly to these places. In this way. avoiding copious injection, he is able to treat the abnormal processes without irritation or damage to the sound portion of the urethra. The most useful applications are silver nitrate and argyrol in varying strengths. The surgeon should not HYPOSPADIAS AND EPISPADIAS 459 use oil or vasclin preparations as lubricants to the urethroscope, for the}- smear the field and interfere with the proper action of applications. There is no better lubricant than glycerin. It may seem necessary to use cocain in some cases, but this should be avoided, so far as possible, lest it also modify the action of the silver drug. HYPOSPADIAS AND EPISPADIAS Hijpospadias is an abnormality of the penis due to defects in devel- opment. ^ The urethra opens short of the meatus. Hypospadias results from a failure of the two lateral halves of the penis to unite on the lower median surface. Hypospadias is not very uncommon. Epispadias is # / Fig. 281. — Beck's operation for balanitic hypospadias. Line of incision. due to a failure of union of the upper penile surface, and is rare. I referred to it in discussing exstrophy of the bladder, and will say nothing further of it here, except to observe that hitherto most attempts to cure it by operation have been discouraging.^ 1 For an encouraging case see Carl Beck, A New Method of Operation for Epis- padias, Med. Record, March 30, 1907. 460 GENITO-URINARY ORGANS Hypospadias is of varying degrees, and frequently has been relieved or cured by operation. It may appear as a mere enlargement of the meatus downward, or the urethra may end and discharge above the glans, or in the ]jcrincal form the urethi'u may end at the scrotum. The symptoms and annoyance of the condition vary with the location of Fig. 282. — Beck's operation for hypospadias. the urethral exit. If the exit be in the glans, there results discomfort merely and soiling during micturition, but there is no interference with procreation. When the urethra terminates near the root of the penis, however, both micturition and coitus are seriously interfered with, and procreation is impossible. Fig. 283. Fig. 284. Figs. 283 and 284. — Stinson's operation for hypospadias. Shows incur\'ation, prepuce retracted: .4, Shows urinary orifice in body of penis; B, shows short blind groove in body back of glans penis. The treatment of balanitic hypospadias (that form in which the urethra opens beneath the crown of the glans) is not difficult and usually is successful through the medium of Beck's operation. This consists in dissecting back two skin-flaps along the urethra for about two inches, and completely dislocating that canal. Then a false canal is formed in HYPOSPADIAS AND EPISPADIAS 461 the glans by plunging through it a narrow-bladed knife, which passes from the site of the present urethral exit out through the site of the meatus proper. The tip of the dislocated urethra is then seized with narrow forceps, is dragged through the new canal, and is stitched to the meatus. The skin-flaps are then replaced. Usually this operation Fig. 285. — Shows urethral orifice (A) slit up to No. 33 French, separated from its surroundings, and edges trimmed evenly. B shows blind groove as in Figs. 283 and 284, but with prepuce well retracted. C, C, C show incisions made for the formation of the new urethra. Fig. 286. — Shows incisions made and flaps of mucous membrane and skin being dissected up for new urethra in the glans and body of the penis. C, C show raw surface of the glans after lifting flaps. results in a complete cure, but narrowing at the proper site of the fossa navicularis may occur after the operation and necessitate subsequent sounding. The treatment of penile or perineal hypospadias is by no means so easy, and is certainly difficult of demonstration, I have employed with satisfaction the method described by Stinson ^ This Fig. 287.— The same as Fig. 288 ex- cept that dotted line {D) show flaps brought edge to edge. Fig. 288.— Shows the edges of the flaps taken from the glans and body, sutured to each other to form new urethra. writer lays stress on the importance of rectifying the clown curve of the penis, which is found at the site of the urethral orifice. This incurvation is remedied by dissecting the urethra from its attachments at that point and dividing all constricting bands by transverse incisions, so as thor- * J. Coplin Stinson, Improved Operation for Hypospadias Involving the Glans and Penile Portion of the Urethra, Jour. Amer. Med. Assoc, December 2, 1905. 462 GENITO-UIUNARY ORGANS oughly to straighten the organ, taking pains at the same time not to damage the corpora cavernosa. The further operation is briefly as fol- lows: (1) Drain the bladder by perineal section and maintain the drain- Fig. 289.— Shows same as Fig. 288, A, and anastomosis made between the new and old urethral orifices. B shows the end of new urethra in glans penis. D shows raw surfaces of glans and body- whence the flaps have been taken. Fig. 290. — Shows the newly placed prepuce, cut down the median line and its layers of mucous membrane (E) and skin {F) being dissected from each other ready to be used to cover com- pletely the raw surfaces of the glans and body of the penis, and also to bury the stitches uniting the edges of new urethra and forming anastomoses between the new and old urethras. age during the patient's convalescence from the plastic operation on the penis. (2) Enlarge the urethral orifice with a No. 33 French sound; Fig. 291. — Shows layers of mucous membrane (E) and skin (F) separated from each other (shown on the right side of figure) trimmed, put in place in their respective positions, and sutured to the vertical cut edges of the glans and body, whence the layers were taken to form new urethra {E and F) (shown on left side of figure). The raw surface on left side is completely covered by the mucous and skin layers, which are also sutured transversely to each other. form a new canal by turning over longitudinal flaps of skin and mucous membrane, and sew these flaps together longitudinally, skin side in, and to the old urethra at their proximal end. This establishes a new urethral HYPOSPADIAS AND EPISPADIAS 463 canal The hood, or prepuce, is employed to cover over the raw surfaces. In order to bring this loose skin of the hood into position for this pun30se, it is dissected back for a short distance from the corona; a transverse split is then cut in it on the dorsum, and through this slit the glans penis i. passed. As a result of this maneuver practically the whole of the prepuce lies flapping beneath the glans and is ready to be utilized tor Fio-. 292. — Shows separation of pre- putial''hood (F), which consists of two layers, skin (E) and mucous membrane {H). Fig. 293.— Shows the preputial hood brought down underneath the glans by carrying the glans through the transverse opening in the prepuce. E shows layer of mucous membrane. F shows layer of skin. covering in the raw surface over the urethra. The loose prepuce is now cut down in its median line, if necessary, and its layers of mucous mem- brane and skin are dissected from each other, are trimmed as required and are adjusted and sutured to the vertical cut edges of the glans and to the body of the penis, so as accurately to cover m the raw surfaces. If the original deformity presents as a perineal fistula, the raw surfaces Ficr 294— Shows the layers of mucous membrane and skin as in Fig 284 F, sutured in tlieir new positions to the vertical edges, transversely to each other the surfaces on the under aspect of the glans and body of the penis. V\ mie tne cux ao the median line was made in this case, usually this should not be done. left by the infolding of skin in the operation may be covered by a loose flap taken from the scrotum. After completion of the operation the whole wound must be dressed carefully, and the part suspended m proper bandages, and the patient must be put to bed for ten days at eas ^ During this time there will have been no soihng by urme as the uime is drained away through the perineum. At the end of ten days a catheter 464 GENITO-URINARY ORGAN'S may be passed throiifih the newly formed urethra into the bladder, and the perineal wound ma}' be allowed to close. This is one of numerous Fig. 295. Fig. 296. Fig. 297. Figs. 295, 296, and 297. — Showing the correction of the convexity and the trans- verse constrictions on the upper surface of the body by making al^out an inch long vertical incision in the median line backward from the transverse incision made in separating hood and dissecting up and bringing forward and suturing it in tlie -same line continuous with the transverse incision. This shortens the anteroposterior measurements and increases the transverse measurement. operations devised for the correction of hypospadias. I have found it satisfactory and recommend it. The Testicles Diseases of the testicles, of the vasa deferentia, and of the seminal vesicles are closely associated, and a clear comprehension of the anatomy of these parts is essential to the surgeon. In fetal life the testicles lie within the abdominal cavity, but at varying times, usually in the seventh or eighth months of intra-uterine life, they descend through the inguinal canal and are found in the scrotum at birth. In a considerable number of male infants, however, one or both of the testicles are found un- descended at the time of birth, an abnormality which may well be a cause of serious anxiety to the child's parents when they regard his future. UNDESCENDED TESTICLE i Lack of descent of both testicles may threaten sterility, for after puberty undescended testicles seldom functionate. Furthermore, in any case of undescended testicle, whether the deformity be double or single, the retained organ is peculiarly subject to malignant changes, so that sarcoma of the undescended testicle has come properly to be dreaded. I have seen two grievous examples of this calamity. For this reason, when I am consulted by a man himself the victim of un- descended testicle, I advise removal of the organ, for it is functionless in an adult, and liable to become the seat of sarcoma. In boys below the age of puberty, however, it is rea.sonable to attempt a proper placing of the dislocated organ. In a great majority of cases it is found outside of or within the inguinal canal, rarely within the abdominal cavity. In any case it may often be brought down into proper position. For cen- turies surgeons have endeavored to correct the deformity of undescended ^ Walter B. Odiorne and Channing C. Simmons, Ann. Surg., 1904, vol. xl, p. 962, present an admirable resume of this subject. UNDESCENDED TESTICLE 465 testicle, but with varying success. Certain procedures, however, have come to be regarded as serviceable, and in some half-dozen instances I have been satisfied to follow the technic of Bevan, who has operated satisfactorily on a large series of cases. ^ Bevan points out that, for clinical purposes, we may divide the condition of undescended testicle into four groups : 1. Simple failure of the vaginal process to close, giving us the picture of a congenital inguinal hernia. 2. Incomplete closure, complicated with such conditions as hydro- cele of the cord. 3. Undescended testis, which presents four types: (a) in the ab- domen in about its original position: (b) at the internal ring; (c) in the canal ; (c/) external to the external ring. Fig. 298. — Bevan's operation. Inci- sion through skin (3), superficial fascia (4), and external oblique (1); 2, cremas- teric fascia (Bevan in Keen's Surgery). Fig. 299. — Bevan's operation: 1, Point where vaginal process of perito- neum is cut; 2, vaginal process open, ex- posing the testicle; 3, testicle (Bevan in Keen's Surgery). 4. Misplaced testicle: (a) in the perineum; (b) on the thigh below Poupart's ligament. He further points out that statistics show the deformity to occur at least once in 500 male children. Bevan asserts also that an operation to bring the organ down into the scrotum practically always is possible, and that there are few cases in which an operation is not indicated. As I have stated, I limit my operations for proper placing of the organ to the case of boys, and believe strongly that the undescended testicle in a man should be excised. Bevan's operation for undescended testicle is performed as follows — and the sketches adapted from Bevan's article will illustrate the theme : ' Arthur Dean Bevan, The Surgical Treatment of Undescended Testicle, Jour. Amer. Med. Assoc, September 19, 1903. 30 466 GENITO-UKIXARY ORGANS Cut down upon the groin as though for the operation of inguinal hernia; open the inguinal canal, and lay bare the cord, testicle, and vaginal Fig. 300. — Bevan's operation — step 3. Showing vaginal process cut across above testis. process (the large peritoneal sac containing the testes, and continuous with the. peritoneal cavity). Open the sac, expose the testicle, and re- Fig. 301. — Bevan's operation: 1, Upper end of vaginal process of peri- toneum ligated; 2, purse-string suture closing lower end of vaginal process and forming a tunica vaginalis for the testicle (Bevan in Keen's Surgery). Pig. 302. — Bevan's operation. Cord lengthened and testicle freed and ready for replacement; 2, the spermatic vessels; 3, the vas deferens (Bevan in Keen's Sur- gery). duce any hernia which may be present. Then cut across the vaginal process above the testicle and secure the proximal stump as in the case UNDESCENDED TESTICLE 467 of a hernia. Sew up the distal portion of the vaginal process about the testicle, and so furnish that organ with a tunica vaginalis. It now remains to bring the testicle into the scrotum, and this is done by a process of traction on the cord and the division of retaining bands. To this end the cord is stripped up, leaving nothing but the vessels and the vas, which in turn must be separated carefully from the parietal peritoneum. By this means, in nearly all cases, the cord may be elon- gated satisfactorily. A pocket in the scrotum is then readily made with blunt-pointed scissors and the fingers; the testicle is dropped into the pocket and is held in place by a catgut purse-string ligature, passed subcutaneously about the neck of the scrotum. The surgeon then restores the wounded canal, sews up the inguinal hernia, and dresses the Fig. 303. — Bevan'6 operation. Mak- ing pocket in right side of scrotum for reception of the testicle (Bevan in Keen's Surgery). Fig. 304. — Bevan's operation. Su- tures closing the wound (Bevan in Keen's Surgery). wound with a firmly applied spica bandage. The patient should be kept in bed for two weeks at least after the operation. In rare cases one finds that the cord cannot properly be drawn down and that this is due to short spermatic vessels, and not to a short vas. Bevan has found, and his experience coincides with my own, that the spermatic vessels may be cut away in such cases, without danger, leaving the vas and its vessels only. When this is done, a sufficiently long cord is obtained. Absence of the testicle is a condition allied etiologically to unde- scended testicle. In two cases of apparent double undescended testicle I have been unable at operation to find more than one testicle in each patient. I did find, however, on the opposite side, an attenuated cord, terminating in a pinch of tissue which doubtless represented a rudi- mentary testicle. In such a case the cord with its terminal, useless 468 GENITO-URINARY ORGANS tissue should carefully be dissected away, while at the same time the undescended organ on the other side should be brought down into the scrotum. WOUNDS AND CONTUSIONS OF THE TESTICLE Wounds and contusions of the testicle are discussed by most writers on the surgery of this organ, but in truth such wounds and contusions differ in no essential from wounds and contusions of any of the soft parts, and the extent of treatment depends upon the extent of the lesion. The damaged structures should be cleaned up thoroughly and supported upon a pillow, between the legs, or on a towel shng. Mere contusions should be treated on the lines I have laid down for the treatment of epididymitis, because an acute and painful exudate with swelling is wont to occur. If the scrotum is found torn open with the testicle exposed or lacerated, the injured parts should be repaired so far as possible, and the testicle should be replaced in its normal coverings. Do not suture the proper tunic of the testicle (tunica albuginea). Take pains to drain carefully the vaginal sac, lest a troublesome hematoma form within it. The soft parts should be sutured with interrupted silkworm-gut stitches. Castration rarely is required in these cases, but w^hen necessary, on ac- count of sloughing, may be performed as a secondary operation. Hematocele of the tunica vaginalis is a condition which I referred to above as a hematoma. It arises from an accidental injury or may occur through hemorrhage from a vein, wounded in the little operation of tapping a hydrocele. Hematocele of the cord is a condition analogous to hematocele of the tunica vaginalis, and occurs beneath the tissue which surrounds the cord. Obviously, having no marked barriers below or above, it extends up and down the cord and foi'ms a sausage- shaped swelling. Both forms of hematocele may become absorbed under rest and cold applications if the damage is recent and the accumu- lation of blood is small. In the case of long-standing and large collec- tions of blood the surgeon may have to resort to incision and drainage. INFLAMMATION OF THE TESTICLE Inflammation of the testicle proper (orchitis) is an infrequent con- dition, and when present, is usually associated with an epididymitis. Orchitis may be the result of an injur}", or may be the sequel of a gonor- rhea. The treatment which I have described for epididymitis is applic- able to cases of orchitis. You must distinguish carefully the syphilitic and the tuberculous forms of orchitis from the ordinary traumatic and infectious varieties, and from syphilitic e])ididymitis. Syphilitic epididymitis is marked by its slow progress, by its devel- opment first in the globus major, and by the relative absence of pain. Obviously, the treatment is by a supporting bandage and by antisyphilitic remedies. Syphilitic orchitis proper (sarcocele) occurs as an infiltration of the testicle. One finds it usually between the second and fourth years INFLAMMATION OF THE TESTICLE 469 of the syphilis, in which respect it contrasts with syphihtic epididymitis, which develops conimonl}- somewhere between the second and seventh months. In sarcocele there is a slow gunmiatous infiltration, with nodules, either single or multiple, and with little tendency to suppura- tion. Such pain as exists is inconsiderable. The process, if untreated, advances to destruction of the organ and its envelops, to fistula for- mation, and to involvement of the scrotum. In making his diagnosis of these syphilitic lesions the surgeon arrives at a history of syphilis and its sundry manifestations, and differentiates the condition from gonor- rheal complications, which are acute and painful; from tuberculosis, which syphilis most closely resembles; and from malignant disease, which is slow, painful, and is a new-growth, rather than a destruction of tissue. The treatment of the syphilitic orchitis consists always in the adminis- tration of mercury and potassium iodicl, and in the operative removal of detritus and all disorganized tissue. Tuberculosis of the testicle and epididymis is a frequent affec- tion. It is grave. Its treatment is interesting, and has been the sub- ject of sharp debate. The disease is rarely primary, but when it is so, the epididymis is the first portion to be affected, and thence the process extends to the testicle proper. In fact, as Fowler says, the epididymis is the starting-pomt of urogenital tuberculosis in more than half the cases. It is needless to discuss the etiology of tuberculosis within the scrotum further than to observe that it occure at all ages, though it is most frequent in young manhood. Tuberculosis within the scrotum, when present in young men, is primary often. When seen in the very young and in elderly persons, it is most often part of a general tuber- culosis. Tuberculosis of the testicle is seen almost always in the caseous stage, and the caseous deposits are multiple. They break dow^n ^nd form numerous pockets or abscess cavities. The vas is involved for varying distances. The symptoms are insidious, for the disease develops slowly, as a rule, though in the case of a concurrent gonorrheal epididymitis a mixed in- fection results and the progress of the disease is rapid. Ordinarily, tu- berculosis of the testicle gives little pain or evidence of tenderness at first. Gradually the organ breaks down, but the patient's first consciousness of trouble may arise from observing a complicating hydrocele or a slight urethral discharge. Generally, the disease begins in the globus major and extends in both directions. When a swelling of the testicle proper can be felt, one discovers it to be hard and nodular. The nodules in- crease in size and number, they break down, form abscesses with as- sociated pain and tenderness, involve the skin, and produce one or more sinuses. Often, when the surgeon is consulted, he finds a dischargmg fistula leading to the broken-down caseous testicle. In making the diagnosis, when the case is seen fairly early, one must differentiate it from syphilitic testicle. The tuberculous testicle feels nodular; the syphilitic testicle feels uniform and smooth. Sometimes both testicles are involved in tuberculosis. Per contra; double sarcocele (syphilis) 470 GENITO-URINARY ORGANS is extremely rare. When a tuberculous testicle is discovered, the surgeon should examine carefully the prostate, vesicles, bladder, and kidneys to ascertain an extension of the process. Frequently he will find tuber- culous disease of the prostate and vesicles; less often of the bladder, and more rarely of the kidneys. I said that the question of treatment had been hotly debated. The opposing views taken in the discussion were, whether or not castration invariably should be performed. Opinions of surgeons are now fairly unanimous. Castration is the rule — castration unless an extensive general tuberculosis coexists. Tuberculous disease of the prostate and vesicles does not contraindicate castration. When castration is done for tuberculous orchitis, the surgeon should not rest content with the operation, but should prescribe invariably a long course of antitubercu- lous treatment — an out-of-doors life; and the ])atient should continue this until his normal weight is reestablished and his general condition is satisfactory to his adviser. The operation of removal of the testicle (orchidectomy or castration) should be done through a long incision beginning over the inguinal canal and running down on to the skin af the scrotum. The surgeon should tie off the vas high early in the operation, and should perform his dissection from above downward, removing thoroughly with knife and scissors all involved tissue. He should not hesitate to sacrifice large areas of skin. This tying off of the vas high at the beginning of the operation is important, for, as George Walker has pointed out, failure to cut off the vas before manipulating the disease itself may re- sult in the forcing of disease organisms up into the abdominal por- tion of the vas, with a consequent prompt development of tuberculous vesiculitis. The dissection wound in the scrotum should be painted with tincture of iodin, sewed up with interrupted stitches of silkworm or silver, and drained from the most dependent point. If the work has been done thoroughly, convalescence should be short, and the patient should be up and about at the end of two weeks. HYDROCELE Hydrocele means properly an accumulation of watery fluid within a sac, and the term hydrocele is applied to various structures and regions. Commonly, however, we mean by hydrocele an accumulation of serum within the tunica vaginalis. There is also hydrocele of the cord, similar to that hematocele of the cord of which I have spoken. There is con- genital hydrocele, in which case the vaginal process has remained opened, so that the tunica vaginalis communicates with the peritoneal cavity. This condition commonly is associated with congenital hernia. Hydro- cele of the tunica vaginalis may be either acute or chronic. The acute form is associated usually with inflammation of the testicle and epididy- mis, whether resulting from injury or disease. Such acute complicating hydroceles require little treatment beyond the care of the underh'ing lesion. Sometimes, if the accumulated fluid persists for long, it may HYDROCELE 471 be drawn off through a trocar (aspiration of the distended scrotum with a hollow needle). Chronic hydrocele of the tunica vaginalis is the condition com- monly meant by the term "hydrocele." The cause of chronic hydro- cele is not entirely apparent, though such recent observers as Kocher, Langerhans, and Konig have found evidence of inflammation both in the accumulated fluid and in the wall of the sac. Traumatism may be a cause of hytlrocele, and small retention cysts (spermatocele), either in the testis or epididymis, may give rise in turn to hydrocele. What- ever the cause, chronic hydrocele develops slowly, often with thickening of the tunica, and an accumulation of fluid within its cavity. This form of serous accumulation differs markedly in its origin from effusion Fig. 305. — Use of the hydroscope for inspecting a hjairocele. into the pleural cavit}' — an effusion commonly tuberculous. Long- standing hydroceles grow to a great size, and the sac often becomes one- fourth inch thick or more. The tumor ma}^ be as large as a child's head even. It is unilateral generally. The symptoms of hydrocele are annoying rather than painful. Their onset is insidious. There is some sense of dragging and weight, but generally the patient complains of the size onl}" of the tumor. The sac is rather ovoid in shape, and the swelling extends from the tip of the scrotum up toward the inguinal ring. You must differentiate it from inguinal hernia. Both fluctuate, but hydrocele is rather the more tense. Hydrocele does not vary in size with the position of the patient nor is there to be felt an impulse on coughmg. The classic demonstra- 472 GENITO-URINARY ORGANS tion of hydrocele consists in looking through it at a strong light and using as an instrument of inspection a straight hollow tube (hydroscope), which is held firmly against the distended scrotum with the light on the opposite side of the tumor. \\'hen you look through the tube, you will see a translucent zone at the end of the hydroscope if the sac is distended with serum only. In the case of a hernia, such translucency is not ap- parent. There is one source of error in this method of determining a hydrocele : blood in the hydrocele fluid or an extremely thick wall may obscure the light, and one must make allowance for these conditions. Of course, other tumors of the scrotum, such as neoplasms, will obscure the light also. If the case remains in doubt after those tests, there is no harm in aspirating the sac and drawing off the Ikiid for examination. 1 y^ Fig. 306. — Tapping a hydrocele. The outlook is good in cases of simple hydrocele, though extreme thickening of the tunic (peri-orchitis prolifera) may produce pressure atrophy of the testis. The best treatment of hydrocele is operative. PalHative treatment is by the use of a suspensory bandage or by repeated tappings. Some persons, especially debilitated old men, prefer the tapping, and this little operation is not very painful. It may be rendered painless by cocainizing the area to be aspirated. To tap the scrotum, seize the mass firmly behind with one hand, and thus make tense the sac. Plunge the trocar into the sac in front about three-quarters of the way down. Guard the trocar against sinking in too deeply and wounding the testicle by holding the forefinger of the active hand firmly against the cannula about one inch from the tip. Select a spot free from veins, lest a blood- HYDROCELE 473 vessel be wounded and bleed into the sac, thus setting up a hematocele. If tapping only be employed, it must be repeated from time to time as the sac refills. The radical cure of hydrocele may follow tapping if proper injections be made into the sac. George W. Gay writes: " For a radical cure of hydrocele the best procedure I know is the following: draw off the serum, and then inject 2 to 4 drams of a mixture of equal parts of car- bolic acid (95 per cent.), glycerin, and alcohol, and allow it to remain. The pain is not severe. The patient goes about his business, and the cure is reasonably certain." An adhesive inflammation results, which often cures the hydrocele after one operation. I prefer to keep the pa- tient quiet for at least twenty-four hours after the operation, with the scrotum well supported and padded with cotton. Occasionally I have seen this method fail, the failure being due mainly to excessive thicken- ing of the wall of the sac. Under such circumstances, — indeed, under nearly all circumstances,- — if the surgeon so choose, one may revert to some one of the radical operations for hydrocele. It is needless here to discuss these various procedures. Volkmann's operation and Longuet's operation are favorites with many surgeons. For myself I have been abundantly satisfied with the so-called " high operation." This con- sists in cutting down upon the spermatic cord above Poupart's ligament, as in the operation for inguinal hernia; loosening the cord from its bed; enlarging the incision down to the root of the scrotum ; and then everting the hydrocele sac, with the testicle, through the w^ouncl, and separating the tunica from its envelops by blunt dissection, with the occasional cut- ting of fibrous adhesions and enlarged vessels. This brings out upon the abdominal wall the loosely hanging hydrocele mass attached to the cord only. The next step consists in opening the sac and cutting away care- fully the whole of the parietal layer, leaving the uncovered testicle hang' ing at the end of the cord. The testicle is then slipped back into the scrotum and the wound is sewed up. Frequently there is a good deal of hemorrhagic oozing from torn vessels on the interior of the scrotal wall. For this reason it is safe practice to drain with tubing the scrotum through a stab wound at its lowest point. Twenty-four hours of drainage should suffice. I advocate strongly this high operation for the following reasons: it cures hydrocele; it removes the external wound from the scrotal tissues, which are difficult to cleanse and render aseptic; the wound in the groin is far less irritating to the patient during his conva- lescence than is a wound in the scrotum, and it is more easily dressed ; the trimming off of the tunic or the handling of the testicle and frequently associated enlarged veins is simplified by this method. After the operation the patient should be kept in bed for a week or ten days and then be allowed to go about with a suspensory bandage for a month, when all danger of further irritation or recurrence should have disappeared. As for congenital or communicating hydrocele of the new-born the treatment is simple. Usually a compressing truss or pad will bring about obliteration of the open vaginal process. Sometimes aspiration 474 GENITO-UKIN'ARY ORGANS of the sac may be necessary. Rarely, a cutting operation and tying off of the sac must be resorted to, but this need not be done within the first year after birth. Under no circumstances should one attempt to cure communicating hydrocele by strong irritant injections. Spermatocele, a rare form of cystic tumor of the testis, simulates hj-drocele and occurs after puberty. The contained fluid is loaded with spermatozoa. To cure it, try tapj^ing first. If that does not succeed, incise, pack, and drain the cyst. VARICOCELE Varicocele of the spermatic cord is regarded ))y the ordinar}' citizen as a mysterious and baneful affection. Medical students even have been puzzled by it. It is merely a varicose condition of the veins in the cord and scrotum, and, as in the case of varicosities elsewhere, it may be cured by removing the veins. The left side of the scrotum is more com- monly afTected than the right. About 87 per cent, of the cases are on the left side alone; some 6 per cent, of the cases are on both sides, and some 7 per cent, of the cases are on the right side alone. The left side is affected more commonly because the left spermatic vein empties at some disadvantage into the left renal vein and not into the vena cava, as does the right spermatic vein. Moreover, the left spermatic vein lies beneath the sigmoid flexure, which, when loaded, presses upon and tends to obstruct it. It is hard to say just what is the immediate cause of varicocele, though numbers of patients have a story to tell of sudden violent strain preceding the appearance of the lesion. The varix may be trifling or extensive; when extensive, it involves all the veins of the cord and their tributaries, from the external ring to the bottom of the scrotum — and the swelling may be obvious and considerable. Men so afflicted complain of various symptoms — of a sense of weight and drag- ging in the scrotum, groin, and lumbar region, and sometimes of actual pain when standing and on exertion. Some men, especially neurotic persons, describe a loss of sexual vigor and pain on coitus. These sexual symptoms are accepted among the laity as the traditional s3'mptoms of varicocele, so that the surgeon is inclined to believe the annoyance is often as much a mental as a physical one. The diagnosis is easy. The condition is a disease of young manhood ; the patient tells often of the sudden onset of a swelling, and the surgeon finds a characteristic collection of enlarged, tortuous, more or less elon- gated and corded veins, which are commonly described as feeling " like a bunch of worms." One must differentiate varicocele from h3^drocele, which presents a smooth, \miform enlargement, from hydrocele of the cord, which is smooth and fusiform ; and from inguinal hernia, which is smooth, varying in size and characterized by an impulse on coughing. I said that the varices may be cured by cutting out the veins. Some- times, in case the varix is small, the surgeon may prefer to tie off subcu- taneously tw'o or three of the veins. This method is not surely cura- tive. A satisfactory operation is to lay bare the cord in the groin, and TUMORS OF THE TESTICLE 475 to dissect out the veins, leaving one or two small vessels only, and avoid- ing carefully injury to the vas. In the case of greatly distended veins, which enlarge the scrotum downward, it may sometimes be necessary to amputate part of the scrotum with the veins. When this is to be done, the testes must be pushed snugly up toward the groin, when the scrotum may be clamped across and trimmed off and the stump sewed up. Many operations for varicocele are satisfactory in the end, especially Fig. 307. — Subcutaneous tying of varicocele. on account of the relief from mental and sexual annoyance which they afford the patient. I prefer the high operation — cutting dovsTi upon the cord in the groin and removing a section of enlarged veins there. TUMORS OF THE TESTICLE Tumors of the testicle are interesting to the pathologist especially; for there is no organ of the body in which there are so many varieties of structure as in the testicle. Accordingly, one finds there new-growths appearing at all ages. There are three principal types of these tumors: (1) Connective-tissue growths; (2) epithelial tumors; (3) dermoid c^'sts and teratomata.^ ^ An excellent brief clinical resume of these tumors is Sarcoma of the Testicle, A. L. "Wolbarst, Jour. Amer. Med. Assoc, April 6, 1907. 47C GEXITO-URIXARY ORGANS Of the first group, there are benign and mahgnant specimens — fibro- mata, lipomata, niyxomata, enchondromata, osteomata, and myomata. None of these tumors are common. They may be found in children, and the surgeon should remove them, while sparing as much as possible of the testicle and its associated structures. Sarcomata are not especially uncommon. They begin usually in the globus minor, and may progress slowly or rapidly. Some are soft and of quick development; some are hard and may remain apparently quiescent for a long time. The shape of the testicle may remain fairly normal, or it may take on a nodular outline. The round-celled sar- comata are of the more rapid growth. The spindle-celled variety are firmer, and often contain striated muscle-fibers. Sarcomata may not cause any great pain, though frequently they do so in their more advanced stages. If one testicle only is attacked, sexual vigor is not lost to the patient. The differential diagnosis is difficult and sometimes impossible. A long-standing hard nodule in the epididymis is suspicious, especially if it takes on suddenly a rapid growth. Sometimes there is breaking down of the organ with necrosis, hemorrhage, and mucoid softening. Late in the disease the cord and inguinal glands are involved. The surgeon must distinguish sarcoma from cancer, which occurs in middle Fig. 308. — Keyes' needle for subcutaneous ligation of varicocele (Fowler's Surgery). life or later, while sarcoma may be a disease of childhood, — from tuber- culosis, which is characterized by softening and early fistula formation; and from syphilis, which closeh' resembles sarcoma and often can be dis- tinguished from it by its reaction to a course of potassium iodid only. Obviously, the only radical treatment for sarcoma of the testicle is its complete excision, with dissection of the cord and the inguinal lymph- nodes on the side affected. Cancer of the testicle is the important tumor of the epithelial group. It develops in the testis itself and grows rapidly. It causes earlier and more severe pain than does sarcoma. The epididymis is involved late, but the disease, as a whole, develops more rapidly than does sarcoma. The growth may involve the skin, so that the patient may present a foul, ugly, cauliflower tumor. Obviously, complete extirpation of the growth and the adjacent glands is the only rational treatment. Adenoma of the testicle occurs in children and in adults. The tumor grows rapidly without pain, and may reach the size of a child's head. Commonly, it contains cysts. It is smooth, firm, and elastic. The prog- nosis is uncertain, because adenoma may be associated with cancer and sarcoma. Castration is the only remedy. Dermoid cysts and teratomata are not especially common, and CASTRATION 4// usually begin to develop in infancy. They grow to considerable size without causing pain, and may be carried for many years. They re- semble adenomata often, but appear at an earlier age and contain em- bryonic structures — atheromatous fluid with hair, teeth, and bone. As- piration or the .r-ray will confirm the diagnosis often. Sometimes one ma}' remove the tumor and save the testicle, but frequently castration must be our rrsort. TWISTED CORD Twisted cord, or strangulation of the cord by axial rotation, occasion- alh' is seen — a curious and interesting condition. It is analogous to twisting of the pedicle of an ovarian cyst.^ The condition is so unusual that an error in diagnosis readily may be made. The cause of the twist- ing is not obvious, though in eveiy reported case there has been a long mesorchium. A normally placed normal testicle is not likely to suffer torsion. The symptoms are sudden, and follow violent exertion usualh'. There may be a hernia present. As a result of the rotation the vessels in the cord are strangulated, so that the testicle swells and quickly becomes the seat of hemorrhage, necrosis, and gangrene even. There are sudden pain, vomiting, shock, a swelling in the groin, and a swollen testicle readily obvious. There is no impulse on coughing. The condi- tion simulates strangulated hernia, from which it must be distingiushed. The treatment is by immediate operation. If the strangulation is recent, it may be relieved by untwisting the cord, but in most cases the testicle is found gangrenous, so that castration must be done. Such are the tumors and swellings of the testicle. Their diagnosis is difficult often, but their treatment is almost invariably by the opera- tion of castration. CASTRATION In the case of malignant disease, castration should include the whole, or a large part of, the scrotum. In the case of non-mahgnant disease, the tumor may be turned out of the scrotum through an incision in the groin. In either case, when the dissection is completed and the tumor mass is free and left hanging by the cord as a pedicle, the final section of the cord must be made carefully. Do not roughly tie it off and cut it en masse. Such treatment pinches nerves and fails securely to control vessels. Pain ensues, and secondary hemorrhage may take place as the cord slips back. Properly to amputate the cord, dissect carefully across it toward the abdominal cavity, tying the individual vessels as j^ou go; then stitch the stump into the internal ring. After castration the patient should be kept quiet in bed for two weeks at least, that healing may progress properly and that no hernia may develop. See article by Charles L. Scudder, Ann. Surg., August, 1901. PART IV THE CHEST CHAPTER XVI THE BRONCHI AND LUNGS Hitherto in this book we have studied regions and structures readily accessible to the surgeon, but in large part become accessible during the last thirty years only. We have been considering the diseases of organs associated with each other, either in their anatomic relations or in their functions — the organs of the abdomen, the genito-urinary, and the sexual apparatus. The surgeons of two generations or more ago dealt timidly with organs within the abdominal cavity, and somewhat fear- fully with the bladder, kidneys, and testicles even, because those sur- geons knew not how to eliminate sepsis. The abdominal cavity especi- ally was an unknown land to most of them. Our present measure of success in dealing with these organs is known to all the world. In these days we are turning our attention to a new field — surgery of the thoracic cavity.^ We are approaching this field with some hesi- tation, though with less timidity than our forbears felt when they approached the abdomen. The dangers in this new work are not the dangers which confronted pioneers in abdominal surgery. They feared sepsis because they knew not what it meant or how to combat it. We understand sepsis, and usually combat it with success; but in thoracic surgery we must face dangers peculiar to the thorax and peculiarly difficult to meet. When we open the thorax, we have to deal with organs the wounding of which promptly is serious, if not fatal — organs incased in an unyielding cage, organs not readily accessible, of varying con- sistency and dimensions, easily escaping from operative control. In the abdomen you may excise the intestines and stomach, open widely the liver, or remove the spleen ; indeed, many of the abdominal organs can be eliminated without danger to life. The intrathoracic organs, on the other hand, must be approached cautiously, opened with hesita- tion, if at all, and totally removed never. But one must not think of these organs in the chest as inaccessible to surgeons. Constantly, with increasing knowledge, we are more certainly cutting down upon the lungs, the bronchi, and the heart; and with increasing experience we are learning the possibilities of intrathoracic surgery and the extent of our 1 See Trans. Amer. Surg. Assoc, 1909. 478 FOREIGN BODIES IN THE BRONCHI 479 limitations. There is one exception to the novelty of operating for diseases within the chest — empyema and other pleuritic collections have been subject to operation since the time of Hippocrates. When we consider diseases of the bronchi and lungs, we must think of the whole complicated apparatus which extends from the bifurcation of the trachea, opposite the third dorsal vertebra, through the primary, secondary, and terminal bronchi and the whole structure of the lungs, with their intricate arrangement of alveoli, bronchioles, and network of important vessels, all bounded by the visceral pleura. Within this com- phcated mechanism the surgeon operates for the following lesions Foreign bodies in the bronchi. Bronchiectasis. Pulmonary abscess. Pulmonary gangrene. Hemothorax. Tuberculosis. Tumors. Echinococcus cysts. Actinomycosis. Aneurysm. FOREIGN BODIES IN THE BRONCHI Foreign bodies in the bronchi were regarded as fatal up to a few years ago — fatal, if the foreign body lodged and could not be coughed up. Then sundry surgeons devised ingenious measures for opening the pos- terior or anterior mediastinum and performing bronchotomy. But these operations are difficult, with a mortality of almost 100 per cent. In more recent years surgeons who have concerned themselves especially with work upon the throat and trachea have devised instruments by means of which foreign bodies in the bronchi may be discovered and removed through the mouth or through a tracheotomy opening.^ The objects w^hich reach the bronchi must be small enough to pass between the vocal cords, whence they drop into the right bronchus commonly, since that is given off from the trachea at a less acute angle than is the left. Coins and buttons are the objects most frequently in- haled, and usually by children. More than one case of a loosened tracheotomy tube discovered in the bronchus has been reported, and Coolidge pictures pins and a carpenter's nail, while D. W. Cheever graphically describes a beard of wheat flying up and down with res- piration. The lodgment of these foreign bodies induces a variety of symptoms. If the object is small and does not become immediately impacted, the patient experiences a sense of suffocation. He coughs, strangles, and may vomit. There may be pain in the chest, with bloody expectoration. Again, the object may completely plug a bronchus, thus throwing out 1 A. Coolidge, Jr., Boston Med. and Surg. Jour., April 10, 1902; von Eichen, Arch. f. Laryng., Bd. xv, 3. Heft.; A. Coolidge, Jr., Boston Med. and Surg. Jour., October 13, 1904; Carl Beck, Surgical Diseases of the Chest, 1907, p. 239 et seq. 480 THE CHEST of commission a portion of the lung. This is an extremely rare con- dition. If the body remain long impacted, there may result a bronchitis, with asthma, or a pneumonia even; and, most serious of all, perhaps, pulmonar}^ abscess or gangrene of the lung. These foreign bodies lodge in the right bronchus, as I have stated, and the surgeon locates them first by means of the x-ray. Then, with the bronchoscope (Coolidge recommends KilHan's) passed either through the mouth into the trachea or through a tracheotomy opening, the patient being under ether anesthesia, an expert may discover a foreign body and extract it with Killian's force]>s. I have seen Coolidge do a number of these operations rapidly and dexterously, but, as a general surgeon, I have never undertaken them. BRONCHIECTASIS Bronchiectasis (iDronchial dilatation) is one of the intrapulmonary ailments for which rarely surgeons have operated. There is no great enthusiasm for this operation, but occasionally it seems justifiable, and several successful cases have been reported. There are various forms of bronchial dilatation — the cylindric form, in which a single t»ranch or sev- eral branches of the smaller or medium-sized bronchi are involved ; the dilatation of a large bronchus alone, and a terminal, sac-like bronchiecta- sis, developing at the expense of the lung parenchyma. Grawitz reports a case of congenital bronchiectasis in which one of the lower pulmonary lobes had been changed to a lax sac with many cavities. In any case of bronchiectasis there may be a concurrent tuberculosis. Note es- pecially the chronic thickenings of the pleura which frequently accom- pany or are associated wath bronchiectasis. In any form of bronchiectasis the disease nms a chronic course. The first symptom is a paroxysmal cough, most troublesome in the morning; and the cough frequent I3' is associated with violent expectoration, when the patient may raise a great amount of sputum — often several cupfuls — suggesting the rup- ture of an empyema into a bronchus. The sputum may stink, or it may be odorless, and it is often mixed with blood. It is needless to dwell in detail on the various symptoms of this condition, but the diagnosis may be made by physical examination. Percussion and auscultation usually demonstrate signs of a cavity. There may be more or less dul- ness, followed by a resonant, tympanitic note, depending on the amount of contents in the bronchial cavity, and the change of percussion-note is striking also as the patient opens or closes his mouth or changes his position. At times one hears nothing on auscultation; at other times one may discover bronchial breathing, with coarse moist rales. Some- times the x-rsiy will confirm a diagnosis. Serious complications of bronchiectasis are: purulent bronchitis, catarrhal pneumonia, gangrene of the lung, abscess of the brain, and meningitis. Emphysema is fre- quent and important. The treatment of bronchiectasis is nearly always symptomatic, but Tuffier, in his classic monograph, reported 46 cases with 39 operations, GENERAL TECHXIC OF OPERATIXG UPOX THE LUNGS 481 and of these patients 10 died, while 29 recovered. Numerous other reporters show similar statistics. The cases suitable for operation are those in which there is a great dilatation of one bronchus only, and the procedure consists in opening and draining the cavity. Those patients who have been improved or have recovered certainly have experienced great relief, so that we believe the operation for bronchiectasis must seriously be regarded as an important therapeutic measure. So much for the surgery of the bronchi as hitherto it has developed. Before going further into the discussion of intrathoracic surgery let us consider the— GENERAL TECHNIC OF OPERATING UPON THE LUNGS Pneumonotomy obviously means opening into the lung; pleurotomy is an incision into the pleura. These are two common terms with which we are concerned, though Ricketts, in his well-kno^^-n book, gives a list of some 55 special terms dealing with the pathology and treat- ment of lung and pleural diseases.^ Surgeons maintain the importance of occasional exploratory opera- tions to determine the exact nature and location of diseases within the chest, although the a:-ray has rendered such explorations less imperative than they were. The student should remember that the right primary bronchus descends into the lungs at a less acute angle than does the left; that the right lung is made up of three lobes, and the left lung of two lobes, while the extent of the thoracic viscera is from the apex of the lungs about an inch above the level of the first rib, to the base af the lungs, which rests upon the convexity of the diaphragm; while the heart, pericardium, and large vessels occupy an important space in the superior and anterior left central portions of the chest. The mechanical ob- stacles to operations within the pleural cavity are, first and most im- portant, collapse of the corresponding lung, when the chest is opened, with pneumothorax; and the presence of a large, stiff-w^alled cavity. Most writers have maintained that adhesions existing between the pari- etal and ^dscera^pleura are necessary in order that one may operate suc- cessfully upon the lung, because through such adhesions the surgeon may penetrate without danger of infecting the surrounding and uncon- taminated pleura. There are various methods of entering the chest, the two most important being — (1) Through a small opening, bj- the removal of portions of one or two ribs over the supposed site of the lesion, and (2) the turning back of a large osteoplastic flap, as in Schede's operation for empyema. When the large flap is to be turned back, the surgeon should make a wide, U-shaped skin incision, going down directly upon the ribs over the lower part of the thorax in the posterior axillary region, and resecting broadly portions of several ribs — generally the sixth, seventh, eighth, and ninth. By this means a large free open- ing is secured, which enables the operator to work with some freedom inside the chest, to explore thoroughly the collapsed lung, if it is collapsed, 1 B. M. Ricketts, Surgery of the Heart and Lungs, 1904, pp. 279-281. 31 482 THE CHEST and to establish depondont drainage. Before opening the hing, but after having laid bare the visceral pleura, the suregon may wall oil the held of operation with iodoform gauze tampons, or he may provide against infection by drawing up the collapsed lung against the chest-wall and fastening it there with deeply placed catgut stitches in order to bring about atlhesions at that point. This latter UK^thod is advocated by many experienced operators.' The paramount objection to so extensive a dissection lies in the fact that most of the patients sub- mitted to pneumonotomy are in wretched physical condition, little able to endure the shock of a prolonged operation. For this reason Fig. 309. — Schede's incision for opening the chest. the more circumscribed operation must often be the operation of elec- tion. The technic of the circumscribed operation is simple enough. The surgeon approaches the chest through a straight incision along a rib over the site of the pulmonary lesion, and excises quickly bits of one or two ribs. Frequently the lung is adherent to the chest-wall at the point 1 The FelI-0'Dwyer apparatus for inflating the lung is advocated by Matas and DaCosta. It is in principle a competent bellows, by the means of which air is forced into the lungs. The O'Dwyer tube is introduced into the glottis and the bellows is worked by foot-power. This instrument is moderately successful in preventing collapse of the lung. F. T. Murphy also has demonstrated an apparatus which acts on the principle of the Brauer positive pressure apparatus. GENERAL TECHNIC OF OPERATING UPON THE LUNGS 483 of attack. If it is not, the pleural cavity must be guarded by tampons or stitching. However the lung is reached, when it is reached it remains for the operator to search the affected pulmonary area. In regard to this searching again, surgeons have differed in their methods, some usmg a long, narrow-bladed knife, others the cautery, and others the finger supplemented by instruments. I advocate the last method, as it is less likely to damage lung tissue, and it obviates troublesome hemorrhage. Most of these operations give rise to more or less pneumothorax, but this is a bugbear not seriously to be considered. Such operative pneu- mothorax usually takes care of itself, especially if the operation and dressings are done with the lung inflated, either by the Sauerbruch cabinet, or by W. Meyer's or Robinson's differential pressure apparatus. Methods of artificial respiration in lung surgery have not been com- monly adopted up to the time of this writing, but it is probable that Yiulmonary pressure is sufficient to keep the lung expanded when the i)leural cavity is open. The steady expan- sion of the lung is, of course, an enormous assistance in operating upon that organ itself, while at the same time it insures the most thorough evacuation of the chest when the pleural cavity is opened to drain fluids, Sauerbruch dwells especially upon the usefulness of his cabinet when one operates for empyema, and after all intrathoracic operations, when the wounds are dressed, and says further: " All recent empyemas and a considerable percentage of the chronic ones yield quickly without the formation of a fistula; the patient is spared tedious after-treatment and subsequent plastic procedures." The first and one of the most accessible lesions for which we operate is abscess of the lung.^ This condition is not common. It may com- plicate lobar pneumonia or influenza pneumonia, or may occur suddenly in lung tissue previously healthy, from embolism," from the lodgment of a foreign body, or as a complication of some such systemic infection as puerperal fever. The syv^ptoms may be obscure, or they maj" be char- acteristic. The condition is most often mistaken for a patch of pneu- monia or for a localized empyema. The condition of the sputum is the best indication of abscess, and the sputum may be coughed up in large quantities — sometimes as pure pus, sometimes moldy, with a sour or sweetish odor, sometimes fetid. Under the microscope you will find connective-tissue and elastic fibers, and occasionally a deposit of black pigment, with fatty crystals and hematoidin crystals. The diagnosis often is difficult in the absence of the characteristic expectoration. After an attack of coughing look for a tympanitic note over an area previously dull. Abscess of the lung may be confused with gangrene also, but in gangrene the expectoration is extremely foul, and elastic fibers usually are absent. The outlook in these abscess cases is grave, though statis- tics appear to show that the best outcome in the case of pulmonary abscess follows abscess due to pneumonia. Medical treatment some- times results in recovery, but if the abscess persists, especially if it is progressive, the physician should seek surgical advice with a view to operation. I have already described the technic of searching the lung for abscess. It is necessary to establish competent drainage when the abscess is found, and for this purpose there is nothing better than a 1 See important case described by C. H. Cottle and J. R. Edward in Brit. Med. Jour., March 7, 1908. - Trendelenburg's case, Deut. med. Woch., July 2, 1908, quoted in Practical Medi- cine Series, vol. ii, p. 215, series of 1909. GENERAL TECHNIC OF OPERATING UPON THE LUNGS 485 rubber tube wrapped in guuzc. The drain should be changed every two or three days, lest it cause ulceration of a pulmonary vessel and give rise to serious hemorrhage. Several accidents of this nature have been reported. The results of treatment depend somewhat on the nature of the abscess. Pneumonia or influenza abscesses promise well, but abscess due to the lodgment of a foreign body is almost never found. The drainage, dressings, and supplementary care of the patient must be continued for a long time often, and so soon as may be the patient should be given an out-of-doors life. Gangrene of the lung is closely associated with abscess of the lung in its origin and physical signs. I have told already how the foul char- acter of the sputum differentiates it from abscess. Gangrene is a necrosis of lung tissue, produced by putrefactive bacteria, and is either circumscribed or diffuse. It is more rare than abscess. The common factors in its etiology are lobar pneumonia and pneumonia due to a foreign body. Sometimes it is preceded by an infarction. Alcoholic and diabetic subjects are the persons especially subject to pulmonary gangrene. I have already described the treatment, which is similar to that for pulmonary abscess. Circumscribed gangrene is the only form of gangrene amenable to surgical treatment. When the diagnosis is assured, the surgeon should insist upon operation, for spontaneous recovery is improbable. Pulmonary tuberculosis at times has come within the purview of the surgeon, but such tuberculosis must be localized. A large number of operators in France and Germany have made experiments in this field, but such work has not yet appealed greatly to American surgeons. The method is to attack small localized tuberculous processes or cavities by injections of iodoform oil or by actual excision (pneumonectomy), with drainage. The excision should be made with the cautery. In all probability this method will fall into disuse before the superior advan- tages of hygienic treatment and the employment of the opsonins. Echinococcus of the lung is fairly amenable to surgical treatment, and the lung, after the liver, is the organ most frequently attacked by echinococci. There is but one cyst cavity in the lung, as a rule, and this cavity may become extremely large, so as to fill completely one pleural sac and displace neighboring thoracic and abdominal organs. Strangely enough, small cavities may produce no symptoms for a long time, but large cysts induce sensations of tension, pressure pains, and dyspnea. Sometimes the cavity opens into a bronchus, so that the patient coughs up great quantities of pus and organisms. Unless the organism has been discovered, it is impossible to make the diagnosis. The organism may be isolated from the sputum or may be secured by aspiration. Echinococ- cus of the lung simulates pulmonary tuberculosis, or, when the cavity is large, suggests an intrathoracic neoplasm. The results of surgical treatment have been brilliant. For instance, Tuffier reported 55 recov- eries out of 61 cases. Simple aspiration and washing out of the cavity is a dangerous procedure, and must be reprobated, because the cleansing fluid may flow into a bronchus and flood the lungs. The surgeon should 486 THE CHEST institute abundant drainage in the manner I have already described. In most cases recovery is slow, but usually certain. Pulmonary actinomycosis demands a word in passing, though primary actinomycosis of the lung is rare. It is needless to describe in detail the character of the slowly advancing disease, which begins usually as a destructive inflammation about the bronchi, and involves gradually considerable areas of lung tissue, reaching finally the pleura and involving the skin, where it manifests itself in swellings and sinuses. The disease is mistaken commonly for tuberculosis. The few operations undertaken hitherto have been limited to opening, cureting, and drain- ing sinuses and abscesses. Very few cures are reported. Cancer of the lung (primary) does not seem to be especially rare, but its diagnosis is so difficult that operative treatment must be uncommon. It is mistaken for tuberculosis, chronic pneumonia, and pleurisy, though the x-ray may give valuable information as to its character. Circumscribed tumors, as large as a hen's egg even, rarely can be detected unless they are on the surface of the lung. Occasion- ally bits of the tumor in the sputum have furnished evidence on which to found a diagnosis. Seldom is there a ])louritic effusion, because the pleurae become adherent. The ordinary physical examination suggests merely a localized consolidation of lung tissue, but the wasting and ca- chexia, with the examination of the sputum, may determine the diag- nosis. Advanced cases of pulmonary cancer cannot be cured, but a few instances are reported in which small circumscribed ]3ulmonary growths associated with tumors of the chest-wall have been removed successfully. The Sauerbruch cabinet is an important aid in such work. Sarcoma of the lung is less common than cancer. The spindle- cell variety is seen occasionally, though a rare form of lymphosarcoma is described. The symptoms are misleading. As in the case of cancer, there is pain in the side, and a sense of oppression and cough, thought to be due to a persistent bronchial catarrh. The sputum is not charac- teristic. Metastases are more common in sarcoma than in cancer, and appear as direct involvement of neighboring organs. Surgical treat- ment of sarcoma is similar to that of cancer. Secondarily maHgnant disease of the lungs, associated especially with malignant disease of the breast, is always inoperable. The benign tumors, so familiar in other parts of the body, are al- most unknown in the lungs so far as surgeons have investigated, al- though such growths occasionally are found postmortem. Injuries of the lung are nearly always associated with complicat- ing injuries to the chest -wall, and are due to crushing blows or penetrat- ing wounds. So far as the lung is concerned, the interesting and sig- nificant symptom to be combated is hemorrhage. The blood may be expectorated or may fill the pleural cavity as hemothorax. The treat- ment is conservative in most cases. The hemorrhage is not often alarm- ing, and is controlled by keeping the patient recumbent and quiet, and by snugly strapping and bandaging the chest. Sometimes, how- ever, continued alarming hemorrhage persists, so that it may seem best GENERAL TECHNIC OF OPERATING UPON THE LUNGS 487 to the surgeon to operate for the purpose of controlKng it. In such cases one should open the chest widely through an osteoplastic flap, should wipe out the blood and clots from the pleural cavity, and should seek the bleeding vessel. Seldom can such a vessel be tied, unless it is near the lung surface, but the wound may be opened with the cautery and packed with iodoform gauze, so as to control the bleeding. Drainage must be employed in these cases also, and particular care must be taken to strap and bandage the chest after the operation. The great sub- sequent distress of the patient should be relieved by small and fre- quently repeated doses of morphin. CHAPTER XVII THE PLEURA Diseases of the pleura are subject to surgical operations more com- monly than any other diseases within the thoracic cage. I have said that Hippocrates was cognizant of such operations. From his time to the present gradually an improved technic ha.s been evolved, but even yet we cannot say that a technic for operations upon the pleural cavity has been perfectetl. The cavity of the pleura is of simpler anatomic arrangement than is the cavity of the peritoneum, though it is quite analogous to the latter. The pleura is like a huge lymph-sac or bursa, interposed between the lung and the chest-wall. Its inner or visceral layer inwraps closely the lung and great vessels, while the outer or parietal layer is stretched over the inner wall of the thorax. The pleura has the structure and functions of other serous sacs. It is abundantly absorbent of toxic products; it secretes an abundant fluid when irritated. \Mien normal, its smooth, shining, inner surfaces play over each other with the rise and fall of the chest. The ordinary movements within the pleural sac are far less excursive than are the movements within the peritoneum, for the play of the lungs and thoracic wall is relatively slight. From such con- siderations the reader will perceive that diseases of the pleura, though vital and troublesome, are not so intricate as are diseases of the peri- toneum. For the sake of convenience let us consider diseases of the pleura under the following headings: Inflammatory effusions, hydro- thorax, hemothorax, chylothorax, tuberculosis, and tumors. INFLAMMATORY DISEASE Inflammatory disease of the pleura rarely is primary. In the majority of cases it is an extension from disease within the lung or some other neighboring organ or structure — the liver, the peritoneum, the spinal column, the ribs. In recent years we have found many of these so-called simple effusions to be tuberculous. Pneumonia also is a com- mon cause of pleuritic effusion. " Catching cold " may be a possible cause of effusions, and it is certain that many infections of the pleura are coincident with sundry joint infections — the origin of both being often difficult to determine, though an invasion of organisms through the tonsils or through the intestinal mucosa frequently explains the trouble. Effusions into the pleura may be general or may be localized and pock- eted. General effusions fill the pleural cavity affected, compress the lung and heart, and bulge into the intercostal spaces, so that in ex- treme cases one lung is thrown out of commission and the heart is 488 INFLAMMATORY DISEASE 489 dit?locat,cd. Localized or pocketed effusions arc confined by adhesions between the visceral and parietal pleurae, so that the collections impinge upon the lungs over limited areas only. With an understanding of the pathologic anatomy the reader will conceive at once what must be the symptoms produced, though he will remember at the same time how symptoms will vary with the under- lying or associated conditions — pneumonia, phthisis, and the like. Simple serous effusions cause mild symptoms, as a rule. The sharp, agonizing, initial pain of pleurisy precedes the effusion, and is due to the irritating contact of opposed, dry, inflamed layers of pleura. With the onset of effusion the layers are separate and pain is allayed. Then there ensue dyspnea, a varying fever, and constitutional signs. r^"**®-.. fc>».-^' Fis;. 311. — ^Thoracentesis. Treatment. — In a great many cases these simple effusions are ab- sorbed and their treatment is within the domain of the internist, with whose examination of the chest, by percussion and auscultation, we need not concern ourselves here. A considerable proportion of cases do not improve under medication, but may clear up quickly as the result of aspiration. Aspiration is best performed with a trocar, cannula, and suction apparatus, and the fluid withdrawn should always be examined critically in order to determine especially the presence in it of pus, of tubercle bacilli, or of other organisms. Sometimes guinea-pig inocula- tion alone will demonstrate tuberculosis. The distinction between a 490 THE CHEST simple serous effusion and a purulent effusion is one of degree only. The serous effusions contain few leukocytes and few organisms. As a rule, then, a simple serous effusion will clear up after one or two aspirations, provided the operator has not infected the cavity at the time of aspirating. When the fluid in the chest has, become purulent, the condition is one of pyothorax. PYOTHORAX Commonly, we speak of such collections of pus as empyema} The pathologic and bacteriologic conditions vary in empyema, depending on the nature and source of the organisms. Pneumococci in the pus and an associated pneumonia are common in children; pneumococci, streptococci, and tubercle bacilli are found at all ages. Sometimes there are present organisms of decomposition. The pneumococcus pus is creamy or light green in appearance, nearly odorless, often full of large coagula, and easily disposed of by operation. The pus of tuberculosis nearly always is due to a mixed infection; it may be thick or thin, odorless or offensive, while the pus due to saprophytic bacteria is thin and very foul. These various collections of pus cause various symptoms, in their turn, not differing materially in character from the symptoms of a simple effusion — discomfort, dyspnea, fever, and debility. But the symptoms do not subside when pus is present. Rarely, nature may find a vent for the fluid through the bronchi or through the chest-wall, but generally, if let alone, the process goes on. The pleura becomes more and more thickened, the lung more compressed and useless, and the thoracic cage fixed and deformed, so that in the course of time the patient presents himself as an emaciated, cripjDled, gasping, distorted invalid. One invariable rule must guide us in the treatment of empyema. Drain the pus at once, as soon as it is discovered. Discover it more promptly than is now done always. If you have to deal with a chest which shows the physical signs of fluid, the nature of which is not ap- parent, do not await developments, but aspirate to ascertain the nature of the fluid, and, if you discover pus, operate forthwith. There are two leading t^^Des of empyema — leading types as regards their bearing on the nature of the operation — acute and chronic em- pyemata; and their treatment often is radically difficult. Take pneu- mococcus empyema as an example of acute empyema: empt}' the sac and establish drainage in a simple manner; employ general anesthesia, as a rule; ether carefully given by an expert, with the patient in a sitting position, is no more dangerous to the lung than chloroform, and is less likely to depress the heart. If the empyema is on the left, and if the heart is greatly dislocated, it is wise often to aspirate off the pus, a part at a time, lest sudden relief of pressure dislocate a possible cardiac thrombus, and kill the patient — an accident by no means unknown. * The term "empyema " is usually applied to a collection of pus in the pleural cavity, though we use it also to denote similar collections in the gall-bladder, the antrum of Highmore, etc. PYOTHORAX 491 Ordinarily, however, such preliminary aspiration is needless. Cut down upon the seventh or eighth rib, in the axillary, anterior axillary, or posterior axillary line, using either a transverse or a longitudinal in- cision; free the rib for about four inches; dissect off the periosteum with a blunt instrument; open and drain the pleural cavity, and insert a rubber tube — the best of which, for this purpose, is Henry's rubber drainage-tube or bobbin, which is self-retaining, and does not protrude either into the cavity or beyond the skin. Another admirable method of securing drainage is to stitch the parietal pleura to the skin. The opening must be lightly tamponed to prevent too early glueing up. It is not wise Fig. 312. — Resection of ribs (after Brewer in Keen's Surgery). to wash out the cavity unless too abundant coagula are present. In such case usually one may wipe them out or gently irrigate the cavity before inserting the tube. Then sew up the skin-wound about the drainage opening and apply an abundant absorbent dressing. In most cases, if all goes well, especially if the case has been taken early, prompt con- valescence will ensue. The patient should be encouraged to sit up as soon as he is strong enough, and should be taught graduated breathing exercises in order to encourage lung expansion.^ ^ See p. 483 for account of the Sauerbruch cabinet and its advantages in the ope- ration for empyema and for subsequent drainage. 492 THE CHEST I have recommended excision of a rib for drainage, and I repeat that recommendation ; an excision is preferable to mere incision and drainage between ribs. The operation between the ribs fails to provide an avenue for proper inspection of the chest and for long-continued drainage. Be sure not to remove a rib behind so high up that the scapula may fall over it. If you operate through the back, take the ninth rib, and not the eighth or seventh. In some cases the diaphragm rises as high as the fourth or fifth inter- space, and lies close against the chest-wall behind. Be careful not to cut through the diaphragm in opening the chest. Most surgeons have been caught in this pitfall. The treatment of chronic empyema is a different matter from that of acute empyema, but if all acute empyemas were operated upon prop- Fig. 313. — Osteoplastic tlioracotomy (after Brewer in Keen's Surgery). erly and promptly, chronic empyema would almost cease to exist. I beg the student to bear in mind carefully the distinction between the two conditions, acute and chronic empyema, and especially the distinc- tion between methods for their relief. In chronic empyema the pleurse become greatly thickened, so that those membranes assume the ap- pearance of tough, strong, and tenacious envelops incircling the pus- cavity, lining the wall of the chest, and covering the surface of the lung corresponding to the affected area. One perceives, immediately, there- fore, that mere aspiration or simple drainage of such a cavity cannot bring about a permanent cure, for the stiff wall of the cyst cavity re- mains after drainage, holds the lung away from the chest, and persists as a pus-secreting membrane. How shall we close up this abnormal cavity? Three methods within PYOTHORAX 493 recent years have come into vogue, and these methods or their modifi- cations often result successfully: Estlander's operation; Schede's opera- tion, and Fowler's operation, sometimes called the operation of Delorme. All these operations are dangerous, and increasingly dangerous in the order I have given. In cases of chronic empyema the surgeon is dealing with patients weakened by long-standing illness. They endure badly capital operations, so that frequently it is necessary to proceed with these maneuvers in detail. I have operated by Schede's method on the same patient seven successive times before curing him. In a word, Estlander's operation consists in removing part or all of the ribs over the affected area, which may mean all the ribs on one side, from the second to the ninth inclusive. This allows the chest-wall to fall in and the parietal pleura to become adherent to the visceral pleura. Various Fig. 314. — Bryant's operation (after Brewer in Keen's Surgery). incisions are employed by various operators — the T-incision; the L-inci- sion; the U -incision. The U -incision is the one I prefer as I picture it in Fig. 314. Turn up a great flap of the soft parts, expose the ribs, cut up each rib to be excised and break it away with the periosteum in either direction. Posteriorly it breaks off at the angle, and anteriorly, at the costal cartilage. In many cases it may be advisable to cut the ribs away carefully over a given area. After removing the ribs, replace and sew up the soft parts and provide adequate dependent drainage. Convalescence is slow, and resulting deformity is the rule, but a fairly competent, useful lung is sometimes obtained. After this operation, as after all other opera- tions for chronic empyema, the patient should be encouraged to lead an out-of-doors life and practise pulmonary gymnastics — walking and hiU- climbing, having due regard always to the condition of his heart. 494 THE CHEST Schede's operation is a modification of Estlander's. Not content with removing the ribs, Schede supplements that procedure by excising all the thickened parietal pleura with the ribs and periosteum. As a result, the soft parts of the chest fall in at once upon and become adherent to the vis- ceral pleura. Fowler's operation, in turn, is an extension of the principle of Schede's operation,' Not content with removing the parietal pleura, he extends the peeling-off process and removes all the thickened mem- brane from chest-wall, lung, and diaphragm, leaving a raw surface and a freed lung, which should now be able to expand and fill the cavity. The subsequent treatment consists in restoring the flap of soft parts and draining the w'ound. The question which confronts every surgeon when he approaches a given case is what operation shall he do, and how far shall he carry his dissection. One cannot lay down any rule which shall meet all conditions, but in general terms it is fair to say that the extent of the operation will depend upon the chronicity of the case, the amount of pleura involved, and, most of all, upon the condition of the patient. Usually one hopes to succeed by performing Estlander's operation, and if that fails to cure, one expects to follow it up with more extensive dissections after the manner of Schede or Fowler. I cannot but regard Fowler's operation as extremely severe, to be approached with hesita- tion and as a last resort.- There has been more or less confusion in the minds of surgeons as to the extent of rib resection which should be done in following Fowler's technic. As a rule, one need resect enough ribs only to allow of free manipulation and dissection within the chest cavity, but in certain cases it seems necessary to make a much wider resection of ribs, as is done in the Estlander operation. After all is said regarding these various radical operations for chronic empyema, we cannot often look for a perfect outcome. The mortality is high ; failure to cure completely is frequent, and those persons even who are reported cured must expect to go through life with seriously crippled lungs and a depressed vitalit}'. The corollary to all this has been often repeated — acute empyema should be operated upon earh', and not allowed to progress to the chronic stage. Hydrothorax develops in the course of some general circulatory dis- turbance, and is of the same nature as abdominal ascites. If the chest become so full of fluid that the lungs and heart labor in action, it may be necessarv' to perform aspiration. Othei-wise the primar}' disease alone should be treated. ^ George Ryerson Fowler, in New York Med. Rec, December 30, 1893, published his first reports of this operation. About this same time Delorme was working at the problem with conclusions similar to Prowler's. Although Delorme presented to the French Surgical C'ongre.ss, in April, 1893, the results of his experiments in the cadaver, he did not do his first on a living patient until some months after Fowler had done so, and Fowler's early work was done without a knowledge of Delorme's experiments. 2 Kurpjuweit, Beit. z. klin. Chir., vol. xxxiii, p. 627, has published statistical results showing that Fowler's operation, known as decortication of the lung, has given a percentage of 35.7 complete recoveries: 19.7 improved; 33.9 unimproved, and a mortality of 10.7. Estlander's operation, on the other hand, shows a percentage of 56.3 cured; 20 per cent, improved; 3 per cent, unimproved, and a mortahtj- of 20 per cent. PYOTHORAX 495 Hemothorax is a subject I have ah-eady mentioned in connection with surgery of the lung. It is produced by penetrating wounds, the crushing of ribs, or the pathologic erosions of vessels in the chest-wall (aneurysm, tuberculosis, etc.). 1 have already indicated the treatment, which is symptomatic generally — rest and bandaging, though rarely, when the symptoms are alarming, the surgeon may be obliged to open the thorax and ligate or tampon the bleeding vessel. Chylo thorax deserves little mention, for it is a rare condition. It results from an injury to the thoracic duct which produces an escape of chyle into the pleural cavity. A positive diagnosis can be made by an examination of the aspirated fluicl, which is cream like, of low specific gravity, and contains sugar, lymphocytes, and minute fat-drops. No active treatment is practicable. Most patients recover under rest and bandaging. Tumors of the pleura attracted some little attention a few years ago, for they were brought to our notice by such interesting writers as E. Wagner, Schulz, Frankel, Lenhartz, and Lochet, but in practice such tumors rarely are seen. Especial attention has been called to a peculiar primary tumor of the pleura, an endothelioma which presents a dif- fuse pleura] thickening, suggesting ordinary fibrous thickening. The microscope shows an extensive endothelial growth. The lung becomes compressed; there is dulness over the affected area, and the aspirating needle draws a chocolate-colored fluid containing characteristic nests and cells. Rare as are privmry malignant growths in the pleura, secondary cancer and sarcoma are common enough, and are the result of malignant disease in neighboring parts, especially in the breast. Malignant involvement of the pleura nearly always produces effusion, which is serous or bloody or beclouded with detritus. In the case of primary endotheliomata operative treatment is of little value. We can do nothing but palliate the symptoms. As for secondary growths, it may rarely seem wise to resect extensively the chest-wall, but, as a rule, we can do no more than relieve pressure by aspiration and give morphin. In case a resection of the chest-wall be undertaken, one should employ a differential pressure apparatus to inflate the lung. Echinococcus of the pleura is rare. I have already discussed this subject under the caption Echinococcus of the Lung. CHAPTER XVIII THE HEART AND PERICARDIUM Fifteen years ago the heart had not been brought within the sur- geon's field, and wounds of the heart especially were held to be beyond surgical treatment. Dennis/ writing in 1S95, says: " The treatment of wountls of the heart consists in lowering the head to prevent cerebral anemia, the administration of opium to relieve pain and to control the inflammation, and the application of artificial warmth to the surface of the body"; but in the very next year, 1S96, Farina reported the first recorded case of suture of the heart-wall for a penetrating wound. Farina's patient died of pneumonia on the fifth day, but that surgeon's operation seems to have been successful in repairing the damage to the heart. Operations on the pericardium antedated operations on the heart by nearly a century, and we read in the memoir of Baron Larrey how that distinguished French surgeon aspirated the pericardial sac in 1798. We see, therefore, that the surgery of the pericardium seemed possible to the older surgeons, and w-e find surgical literature dealing frequently with the subject. The heart and pericardium form a portion of the circulatory appar- atus, and many writers discuss their diseases in connection with the broader subject of circulatory disturbances. It seems more suitable to me, however, to treat of the heart and pericardium from the anatomic rather than from the physiologic viewpoint — to group the diseases of these organs with diseases of the chest, rather than with diseases of the blood-vessels, because clinically the surgeon deals with the heart and pericardium as isolated organs. There are two main divisions of the surgery of these structures: operations for fluid in the pericardium, including adhesions between the layers of that membrane; and opera- tions for repair of penetrating heart wounds. The popular notion that wounds of the heart are necessarily and instantly fatal is erroneous. Surgical writers from Pare to men of our own time relate cases of persons surviving such wounds for a longer or shorter period. Indeed, G. P'ischer, in 1S67, estimated, from a study of 452 cases of wounds of the heart, that from 7 to 10 per cent, of per- sons so injured recovered completely. The fact is known to all physi- cians that pathologic heart ruptures may be survived for a time. I my- self had under my care a man of fifty who survived a cardiac rupture for nine days. Degeneration of the heart muscle renders futile repair of pathologic rents. Aspiration of the right auricle has been done to relieve the engorged heart in cases of acute pulmonary congestion, 1 Dennis' System of Surgerj', vol. iii, p. 218. 496 OPERATIONS UPON THE PERICARDIUM 497 though the operation is desperate and rarely effective. Collections of fluid, from their pressure within the pericardium, may embarrass seri- ously or check the heart's action. PERICARDIAL EFFUSIONS The simpler forms of pericardial effusion may be dealt with by aspiration or incision. In such cases aspiration is comparatively easy and safe, because the heart is crowded back into the depths of the peri- cardium. Aspiration is not safe, however, in cases of purulerit effusion into the pericardium, because then the heart's apex may be held forward to the anterior chest-wall by adhesions. In recent years the possibilities of heart surgery or direct operative dealing with the heart have been made to appear as important future possibilities. George W. Crile, in 1903 and 1904, published an extremely interesting series of experiments and operations on the heart, showing that after apparent death in dogs and in man, even when half an hour of suspended animation has elapsed, the heart may be stimulated to resume its functions by direct rhythmic pressure over the pericardium, or by subdiaphragmatic massage, — the abdomen being opened for the purpose, — supplemented by artificial respiration and long-continued infusion of 1 : 50,000 adrenalin chlorid solution. Harvey Gushing, working in the Hunterian Laboratory of the Johns Hopkins University, has demonstrated the possibility of producing artificial cardiac lesions by intraventricular incisions of the cardiac valves, with a resulting recov-' ery from the operation except for the cardiac lesion. This extremely interesting work suggests the possibility of intracardiac manipulations for the relief of valvular stenoses. Theoretic as these considerations may be, the work of such experimenters has proved conclusively that the heart may be approached and handled with boldness; at the same time the practical experience of many surgeons has shown the reason- ableness and importance of operating upon the heart and pericardium for traumatic lesions of these structures. In all this we are considering a strikingly interesting and Httle explored field for surgery. OPERATIONS UPON THE PERICARDIUM Injuries to the pericardium may require the surgeon's intervention. They occur from crushing blows which fracture ribs and tear the peri- carclium, and they are due to penetrating wounds also — gunshots and stabs. Pericarditis may give rise to serous, purulent, and hemorrhagic effusions. Good practice in these days limits puncture of the pericar- dium to aspiration for the purpose of diagnosis. If fluid is to be evac- uated properly, the pericardium should be opened with a knife. Com- monly, the best place for puncture is in the sixth intercostal space, close to the edge of the sternum, for at this point there is the least danger of wounding the heart or the pleura. Surgeons are not agreed as to the best method for incising the peri- 32 498 THE f'HEST canlium (poricanliotomy). Some suifioons have advocated making a large costocartilaginous flap by cutting through the fourth, fifth, and sixth costal cartilages, and thus exposing a large opening. For many reasons this method is admirable, but there are the objections that it consumes much time and often involves wounding the j^leura. This last objection may not be of serious consequence if the pleura has been damaged already by the violence \vhich necessitated the operation. Mv own dissections of the cadaver have convinced me that Kocher's m Fig. 315. — Kocher's approach to the pericardium. method of approaching the pericardium is. valuable. He makes a rec- tangular incision, one limb nmning down the middle of the sternum, the other outward along the sixth costal cartilage and rib. He turn? up a flap of soft parts with the perichondrium of the cartilage and the periosteum of the sternum. He then divides the sixth costal cartilage, and pulls the sixth rib upward. If he looks for a greater exposure, he divides the fifth and fourth cartilages also. Then the intercostal muscles are stripped off and the internal mammary vessels are exposed. WOUNDS OF THE HEART 499 One now perceives at the bottom of the wound the tough, glistening pericardium, which may be demonstrated more thoroughly by pushing aside with the finger the edge of the pleura (to be distinguished by the pad of fat covering it), together with the intercostal muscle and the internal mammary artery. If the pericardium contain a non-purulent fluid, it is best treated by opening it low down along the edge of the sternum, drawing off the fluid, and sewing up without drainage the wound in the pericardium. The chest-flap is then replaced and repaired, with superficial drainage, to provide for the possibility of an intrathoracic infection. Should the surgeon find a. pyopei-icardium^ present, he must drain the pericardial sac — preferably wath a cigaret wick. Adhesions between the heart and parietal pericardium or chest- wall are due to pericarditis or traumatism, and cause distressing symp- toms—pain, dyspnea, and palpitation. The surgeon treats this con^ dition by separating the adhesions (cardiolysis) or by cutting costal cartilages so as to allow the chest-wall to sink in and relieve the tension of the adhesions. The former operation, cardiolysis, must be performed carefully, and its completion must be abandoned if there appears to be danger of tearing the heart. Section of cartilages is an operation rela- tively safe, and often satisfactory in its results. WOUNDS OF THE HEART Operations upon the heart have been confined hitherto to the repair of heart wounds, and there is the suggested paracentesis auriculi, which is shunned by the wise. Heart wounds cause instant and alarming s3anptoms : pain; hemorrhage, often copious, sometimes slight; pal- pitation; dyspnea; syncope. The symptoms depend on the site and extent of the heart wound. Death is instantaneous if the ventricle is torn widely open or the center for heart-block is damaged, or the auricles injured. Fortunately, the ventricles are the parts commonly injured — the left ventricle much more often than the right .^ A bullet or knife may wound the heart-wall without perforating the ventricle. This superficial wound may bleed profusely and confuse the diagnosis. A perforating wound, if small, may bleed but little, owing to its being closed with every systole by the interlocking of the heart's muscles. Often there is but little external bleeding. An important complication of these wounds is coincident damage to the lungs and pleura, resulting variously in pneumothorax, hemothorax, or pulmonary atelectasis even. The surgeon must take note especially of those victims of heart wound who do not die at once. Such are they in whom operative re- pair of the cardiac wound is imperative. The patient is seen in collapse, gasping, with cold extremities, cyanotic; the pulse is soft and rapid; the heart-sounds are muffled. Frequently there is hemorrhage from the heart into the pericardium, with a consequent throttling of the heart's 1 Ellsworth Eliot, Jr., Suppurative Pericarditis, Ann. Surg., January, 1909. 2 L. L. Hill, Wounds of the Heart, Med. Rec, September 19, 1908. 500 THE CHEST action. If the homorrhao;e continues, the heart will be brought to a standstill. Our one and obvious expedient is to relieve the ]:)ressure by emptying the pericardium, and to check the hemorrhage by sewing up the wound in the heart. The treatment I have outlined should be supi)lemented by proper stimulation — hot bottles and blankets, raising the foot of the betl, a hypotlermic injection of morphin and atropin, the intravenous injection of a pint or more of normal saline solution, with adrenalin (1 : 50,000), and the application of Crile's pneumatic suit, if it is at hand. An anes- thetic rarely is desirable, and if any is given, ether only is permis- sible. Fig. .316. — Vaughan's case of heart suturing (redrawn from sketch): 1, Heart: 2, deep sutures; .3, superficial sutures: 4, pericardium: o, left pleural space: 6, flap of chest-wall, including fourth, fifth, and sixth ribs; 7, outhne of heart. The steps of the operation in detail are these: With the patient in a modified Trendelenburg position, clean up rapidly the skin; enlarge the external wound, and ascertain the condition of the underlying cartilages and ribs. If they are found divided, advance through the opening thus provided. If they are intact, turn back a rib in the fashion I have al- ready described. Seek and tampon any rent in the pleura. Expose the pericardium and find the wound in that membrane; enlarge the peri- cardial wound ; empty the pericardium of blood and clots, and look for the wound in the heart. One may find great difficulty in discovering this heart wound. Gibbon^ reports an interesting and successful case, 1 John H. Gibbon, Jour. Amer. Med. Assoc, February 10, 1906. WOUNDS OF THE HEART 501 in which, being unable at once to discover the lesion by sight or touch, he passed his fingers behind the heart, Hfted it forward to the peri- cardial opening, and so disclosed the heart wound, which was partly filled with a clot, and was situated in the right ventricle, near the auricu- lovcntricidar groove. Having found the wound, the surgeon will make easier the sewing it up, by passing first two deep stay-sutures, one into either edge of the wound, and so holding forward the heart. Use round-pointed intestinal needles. Sew up the wound with a continuous silk or catgut suture, tie it during diastole, and avoid entering the endocardium. Then drop back the heart, sponge out the pericardial sac, and sew it up after providing drainage. Some surgeons protest that drainage is not neces- sary and that it promotes suppuration; but in view of the possibility of further leakage from the heart-wall and of the collecting of blood, serum, or pus in the pericardium, I cannot convince myself that it is safe to leave the sac undrained. Complete the closure of the wound by treating properly any rent in the pleura; drain it, if a rent exists. Re- place the cartilage and skin -flap, and drain the superficial wound also. Apply a large absorbent dressing with a firm swathe, and put the patient quickly into a warm bed. If the patient lives, the surgeon will have an anxious time for a week or more. There are the dangers of recurring hemorrhage, of incomplete drainage, of cardiac collapse, of infection, of pneumonia, and of empyema. The first dressing should be done after twenty-four hours, and after that the various complications must be met and combated as they arise. We are coming to see that wounds of violence to the heart offer brilliant opportunities for the surgeon. Without operation 90 per cent, of the victims die; with operation, 64 per cent., and the mortality is falling. All surgeons are impressed with the importance of prompt repair for penetrating wounds, for stab-wounds especially, as they are least likely to involve the ventricular septum. Shot-wounds are more fatal, for they penetrate deeper than stab-wounds, but shot-wounds even may sometimes be repaired. Too little regard has been paid to the after-effects of crushing wounds which fracture the costal cage and tear the pericardium. From such damage patients may recover, but later develop cardiac adhesions, with dilatation and symptoms of insufficiency. In several such reported cases cardiolysis, or, better, section of the overlying chest-wall, has given marked relief to the symptoms. It may still be proper to feel that the whole subject of heart surgery is sub judice, but there can be no doubt that it offers a widening and im- portant field for surgical endeavor. CHAPTER XIX THE CHEST-WALL— THE BREAST The Chest-wall In the three preceding chapters we have been discussing diseases and injuries of the thoracic viscera — the bronchi, lungs, pleura, and heart. In this chapter we shall deal with lesions of the thoracic cage and its coverings. In general terms, the important external lesions of the thorax may be grouped under inflammations, wounds, and tumors; while far the most interesting of the special conditions in this relation for surgeons are penetrating wounds of the chest and breast tumors. To breast tumors especially surgeons in civil practice have turned their attention for generations, and the accumulated literature of the subject during the past one hundred years is enormous. We are now dealing with diseases on the surface of the body, diseases obvious to touch and sight; and we may well imagine how such disorders in all time must have attracted the intelligent interest of mankind. In like manner wounds of the chest-wall have always been objects of surgical activity, and mil- itary surgeons especially have dealt with them familiarly. We shall not discuss bone fractures in this chapter, but reserve that subject for special consideration in the chapter on Fractures. The soft parts of the chest-wall are subject to such various contusions, wounds, and inflammations as are found in other parts of the body, but certain of these lesions when found upon the chest have their own char- acteristics. CONTUSIONS OF THE CHEST Contusions of the chest may be supercficial or deep, and may be as- sociated or not with damage to the viscera. In any case the pain which is experienced is increased by the movements of costal respiration. Skin-wounds call for the simple treatment which I shall explain in the chapter on Minor Surgery. Wounds of the muscles and ligaments may cause great inconvenience, while damage to the ribs gives rise to ex- cruciating pain. In all cases of thoracic wounds, therefore, the patient experiences peculiar symptoms — intermitting pain, increased by respiration; a fre- quent sense of suffocation; a feeling of collapse and prostation; some- times dyspnea and palpitation. He is most comfortable in the semi- prone or upright positions, and involuntarily he employs diaphragmatic breathing. An unusual but frequently quoted result of severe chest contusion is traumatic asphyxia, a striking case of which condition was reported by 502 PLATE I. Traumatic Asphyxia. Discoloration following forcible compression of the thorax (Beach and Cobb, in "Annals of Surgery," April, 1904). INFLAMMATIONS 503 Beach and Cobb ' a few years ago. I saw the case at the time, and was impressed by the extraordinary appearance of the man, whose pic- ture I reproduce (Phite I). Such conditions are due to heavy crushing forces exerted upon the thorax. The man in question was crushed in an elevator. The discoloration of the skin is due to stasis from mechanical overdistention of the veins and capillaries, and not to extravasation of blood into the tissues. The sharp limitation of color to the head and neck is probalily due to the lack of valves in the jugular and facial veins. The treatment for most chest injuries not involving the viscera consists of repair of the soft parts, the application of an abundant absorbent dressing, and fixation of the chest by plaster strapping, which should immobilize the ribs on the side affected, and should extend well over on to the opposite side, both behind and before. Cases of traumatic asphyxia seem to be little benefited by treatment, though writers have suggested that artificial respiration and the giving of oxygen might be of value immediately after the accident. In the case I have quoted, and in other similar cases which have recovered, the patients got well under rest in bed merely. INFLAMMATIONS Inflammations of the thoracic wall, especially suppurative inflam- mations, may involve much tissue, for the chest is overlaid by a series of broad flat muscles, between the planes of which pus burrows rapidly. Great abscesses form in the back and under the breast, causing severe constitutional disturbance and great local distress. Such inflam- mations must be treated promptly by opening and washing out and draining the abscess cavities. These cases of localized infection are peculiarh' suitable for opsonic vaccination. I have seen prompt and striking improvement follow this treatment. Burns of the chest occur frequently in ci\dl practice. When they are at all extensive, they are grave. Indeed, death may follow apparently trivial bums of the chest. These lesions call instantly for careful treat- ment. One should give morphin to quiet the pain and diminish shock, and should carefully exclude the air by wrapping in oiled compresses covered with heavy absorbent dressings. Boils and carbuncles are often found upon the chest, especially in the thick skin of the back. The treatment of these lesions is that treatment of boils and carbuncles which I describe in the chapter on ilinor Surgery (Chapter XXVI). In addition, they are especially favorable objects for opsonic vaccinations. Tuberculous sinuses associated wath tuberculosis of the ribs, clavi- cles, sternum, and vertebrae burrow through the chest-wall and appear at various points on the thorax. Often they become the subjects of prolonged and tedious treatment. The sinuses must be dissected out carefuUy and the underh'ing tuberculous focus must be exposed and removed. There results generally from the operation a large open wound, which must be packed carefidly and made to heal from the bottom. 1 H. H. A. Beach and Farrar Cobb, Ann. Surg., April, 1904. 504 THE CHEST Actinomycosis of the chest-wall is not uncommon, while rarely echinococcus disease is seen. The surgeon must expose thoroughly these processes and remove or drain them, as best he may, under the circumstances. NEURITIS OF THE INTERCOSTAL NERVES Neuritis of intercostal nerves, commonly known as intercostal neu- ralgia, is a frequent affection, and its sources are manifold. Generally, it is associated with the so-called rheumatoid condition, but it may be due to disease of the nerves themselves, to disease of the cord, to disease of the spinal column causing pressure, to the pressure of tumors directly upon the nerves, or to disease of the ribs. These several etiologic fac- tors must be investigated and the primary causes must be treated. In addition to such traumatic and inflammatory lesions the surgeon will be called occasionally to treat tumors. TUMORS OF THE CHEST-WALL There is a considerable variety of such tumors, which develop some- times from the soft parts, sometimes from the bones or periosteum. Moreover, metastatic tumors from growths in the vicinity, such as can- cer of the breast, attack the chest-wall frequently. There are the com- mon benign tumors, nei-i, sebaceous cysts, ivejis, dermoids, keloids, fatly tutnors, Jibrotriata, neuromata, cavernous hemangiomata, lymphangio- mata, enchondromata, and compound tumors, all of which may disturb the patient by their mere presence, by their size, and by the pain which they cause. These tumors are benign, and may be removed with the knife or cautery. In several instances I have removed successfully nevi and angiomata by the injection into them, .subcutaneously. of several syringefuls of boiling water (Fig. (369), which causes a local necrosis, with resulting absolution of the mass. Sarcoma and carcinoma, primarj^ in the chest-wall, occasionally have been reported. Such tumors are distinguished from benign growths by the rapidity of their development, by the pain they cause, by the appearance of metastases, and by the development of cachexia in the patient. They are, unfortunately, fatal, usually, in spite of the most radical treatment. Frequently they attack the ribs, and they may invade the pleura. It is a serious matter to excise them, but excision offers practically the only chance of cure. If the operation necessitate opening the pleural cavity, the surgeon should employ the Sauerbruch cabinet or some one of the positive pressure apparatus, to maintain a proper expansion of the lungs. It is needless here to discuss the nature and treatment of penetrat- ing wounds of the chest involving the thoracic viscera, as we have al- ready considered this subject in Chapters XVI, XVII, and XVIII. Such, in brief outline, are the diseases and lesions located upon the thoracic wall. AXATOMY 505 THE BREAST There remains for our consideration the subject of diseases of the breast. The breast is the most important and striking landmark upon the chest — the organ pecuHarly Hable to injury, infection, and tumor growth, especially in women, closely connected with the generative function, and of extreme interest to the surgeon. Diseases of the breast have been the subject of intelligent surgical interest for generations, but it is within our own generation only that final and satisfactory conclusions regarding the pathology of this organ have been reached. After Virchow published his observations on cellular pathology and the nature of tumors, some measure of order in our conception of mammary diseases began to establish itself, but even to-day all men are not in accord as to the classification of certain breast tumors, and so lately as 1905 J. Collins Warren wrote, " In no department of surgery has the classification of the diseases of an organ or the pathologic nomenclature been more confusing than in the case of the diseases of the mammary gland." Most physicians, when they think of disease of the breast, think especially of the two most common lesions — cancer and abscess. There are numerous other lesions which we must consider in their order. Let us first, however, study the most common disease, cancer, and sundry less malignant breast tumors with which cancer may be confused. A few words first on the subject of the anatomy and development of the breast must detain us, for without a clear understanding of these matters the reader cannot proceed intelligently. ANATOMY The breast in women — we need not consider here the rare breast diseases in men — extends normally from the third to the sixth or seventh rib, and from the margin of the sternum to the anterior axillary line. It covers most of the pectoralis major muscle, and is easily movable on the fascia of this muscle. Its 15 to 20 milk-ducts terminate by fine openings in the nipple. The areola contains sweat-glands and sebaceous glands, which may become cystic or inflamed. Numerous smooth muscle-fibers run down from the nipple and areola into the substance of the breast, and their stimulation causes an erection of the nipple. These fibers must not be confused with the fibrous processes which radi- ate from the skin of the breast down between the lobules of the gland. ^ Various diseases of the breast may affect the muscles of the nipple and cause the nipple's retraction. Cancer of the breast may affect the fibrous processes of the skin, causing them to shorten, with the effect that the overlying integument appears pitted, with many minute dimples. At different periods of life the breast changes in size and in its histologic characteristics. At birth the gland is represented by a series of radiating ducts lined with an epithehum which is often in a state of active prolifer- 1 The suspensorj^ ligaments of Astley Cooper. 506 THE CHEST ation, causing swelling and tonderness of the babj-'s breast and a deposit of broken-down fat and epithelial cells, which may be squeezed in a milk- like fluid from the nipi:)le. This is the so-called acute mastitis of infants. From infancy until puberty the breast is quiescent. Then comes the hypertrophy of puberty, when there appear acini lined with epithelium and a chdracteri.siic nnjxo)natous connective tis.suc, which develops about the terminal ducts and the acini. Note must be made of this peculiar connective tissue, which was first described by Billroth, for it is the site of important new-growths, usually benign. This is that periductal connective tissue, for the tumors of which ^^'arren^ has suggested an important modified nomenclature. With pregnancy another notable change takes place in the breast. The epithelial activity of the gland is then great, the acini multiply, and, as Warren remarks, the tree may be said to be in full leaf. The peri- ductal tissue becomes stretched and less prominent. After lactation many of the acini disappear, the periductal tissue becomes relaxed, and the breast pendulous. The final period in the life-history of the bi-east begins in middle age. The gland slowly dries up, with obvious changes, noticeable both in the acini and in the periductal tissue. The epithelium no longer proliferates, but degenerates. Ducts become choked with epithelial debris or compressed by the contracting interstitial tissue, and blood-vessels become thrombosed and disappear. These changes are not uniform, but occur in scattered islands throughout the breast, so that the gland takes on the familiar " cobble-stone" feel. With advancing age these degenerative changes continue, so that in old women the mammary gland, much as in infancy, is represented by a few ducts mereh^, near the nipple, and small bands of fibrous stroma infiltrated with fat. The breast receives its blood-supply from the axillary and internal manmiary arteries and from certain branches of the intercostal arteries, and its nerve-supply from filaments of the syinpathetic, the brachial and cervical plexuses, and the intercostal nerves. The lymphatic connec- tions of the breast are far more important than the blood and nerve connections. The lymph-vessels and nodes of the breast are numerous. They are superficial and deep. Some lymphatics belong to the skin, and are found especially about the nipple, whence they penetrate within the structure of the gland itself. All the lymphatics of the breast join at the inferior external margin of the gland in two or three large trunks, which pass upward along the edge of the pectoral muscle and empty into the axillary nodes. The first node of this axillary chain lies on the third rib, beneath the pectoralis major. There are about a dozen axillary lymph- nodes. The more important are grouped about the axillaiy vein, where it receives its long thoracic and subscapular tributaries. Some of the lower cervical nodes, lying close above the clavicle, have h-mph con- nections with the axillary nodes, and the deep lymph-nodes in the retro- mammary fat may communicate directly with the breast tissue. For 1 J. Collins Warren, The Surgeon and the Pathologist, Jour. Amor. Med. Assoc, July 16, 1905. CANCER OF THE BREAST 507 convenience of gross anatomic description the breast is spoken of as divided into hemispheres and quadrants — tlie upper, the lower, the outer, the inner, etc. CANCER OF THE BREAST Cancer of the breast is common. After the stomach and the uterus, the female breast more often than any other organ is the site of cancer. Cancer is the most frequent tumor of the breast — far more common than benign tumors. Statistics vary. Authors estimate the frequency of cancer as between 70 and 82 per cent, of all breast tumors. Not only does cancer develop primarily, but frequently it appears as the outcome of changes in tumors heretofore benign. This is not the place for a dis- cussion of that burning question, the etiology of cancer, but clinicians have come to think that breast cancer, like cancer elsewhere, may in some degree be dependent upon trauma — not trauma in the ordinary Fig. 317. — Acinous and duct cancer (Warren Museum, Harvard). sense of wound or bruise, but trauma in the sense of long-continued irri- tation, such as any actively functionating part must undergo. Cancer of the breast, in most cases, springs from the epithelium lining the acini or from the epithelium lining the ducts. Hence the familiar terms, acinous cancer and duct cancer. Acinous cancer is far the more common. That is a histologic classification, but old-time convention has established a clinical classification which is still in common use among surgeons. For instance, we speak of scirrhus and medullary cancer (or encephaloid) , of colloid, of atrophic caricer, of cancer ew cuirasse and of Paget's disease. By scirrhus we mean a hard growth merely, and this hardness is due to the fact that the tumor contains much connective tissue and little parenchyma. Medullary cancer is softer, because it contains much par- enchyma and little connective tissue. When the tumor undergoes col- loid degeneration, we speak of it as colloid cancer. Atrophic cancer, or " withering scirrhus," produces so great a shrinking of the gland that 508 THE CHEST little of the breast can be found. Then there is the so-called cancer en cuirasse of Virchow, which shows itself as a malignant growth involving extensively the lymphatics of the skin, as well as the thoracic wall. A considerable area of the chest seems to beset in a wide-reaching, firm ^ ^ Fig. 318. — External appearance of scirrhous carcinoma (Massachusetts General Hospital). corslet of disease. Paget's disease of the nipple is a somewhat rare condition, which leads to malignant involvement of the mammary gland. It starts as a chronic inflammation, suggesting eczema of the nipple and areola, and may last several years. It is not a simple eczema, and Fig. 319. — Section of scirrhous carcinoma (Warren Museum, Harvard). does not yield to ordinary treatment. If left unchecked, it proceeds frequently to invasion of the epithelium lining the mammary ducts, until it produces a genuine duct cancer, with all the familiar charac- teristics of that affection. CANCER OF THE BREAST 509 Cancer of the breast, like cancer elsewhere, has no capsule. It progr(\sses by a general infiltration, though the different forms of cancer vary in their life-history, in their symptoms, and other manifestations. Fig. 320. — External appearance of medullary cancer (Massachusetts General Hos- pital). Scirrhus grows slowdy, and may run a course of two or three years. It is most common in women who have borne children. Though not peculiar Fig. 321. — Section of medullary cancer (Warren Museum, Hars^ard). to old women, it appears usually after middle life. The tj^pical forms of atrophic scirrhus are peculiar to persons of advanced years. Med- ullary cancer is more common to persons in young middle life, and is 510 THE CHEST found, rarely, among younji; women oven. I have seen medullary cancer develop ra])idly in an unmarried ^ii'l of twenty-on(\ Medullary cancer may kill the i)atient within a year. Thi.s i.s the foi-m wliich early attacks Fig. 322. — External appearance of colloid cancer (Massachusetts General Hospital). the skin and underlying muscles, and results in the familial' ulcerating, cauliflower growths, which the laity usually associate with cancer of the breast. Not long ago I had under my care a stout woman of forty, the Fig. 323. — Section of colloitl cancer (Warren Museum, Harvard University). victim of one of these tumors, which had destroyed the breast and a large part of the pectoralis major. It presented the appearance of a great granulating wound the size of a dinner plate, and with foul, elevated edges. The progress of all forms of breast cancer is continuous. They CANCER OF TIIK HHKAST 511 invade early the neighboring!; lyniph-notle.s, especially those in the ax- illaiy grou)), whence the disease sjjreads to the lower cervical group. Fig. 324. — Adenocarcinoma (Warren Museum, Harvard University). Late, and more rarely, the subpectoral and the mediastinal nodes be- come involved. The patient dies with distinct metastases often — Fig. 325. — Cancer en cuirasse. cancer of the lung and pleura, of the Hver. the spinal column, or the brain. The exact method of cancer dissemination is still a matter of 512 THE CHEST discussion, and Handlcy* recently has advanced views at variance with those commonly accepted, namely, the belief in a spread throufih the blood and lymph-channels only. He asserts that the dissemina- tion of cancer is accomplished in a more slow and subtle way \)y the actual growth of cancer-cells in all directions, from the tumor center along the finer vessels of the lymphatic plexuses. The author calls this " permeation," and states that it takes place as readily against the lymph-stream as with it. In this way the tissues ai-e involved as by an invisible annular ring-worm, the growth extending like a ripple, in a wider and wider circle, with a healing process going on within its cir- cumference, leaving behind it involved lymph-nodes which persist. y.'& — . n Fig. 326. — Paget's disease (Massachusetts General Hospital). Thus he says a breast cancer with its invisible microscopic extension forms a mass shaped somewhat like a biconvex lens, the thin circum- ference of the lens situated often far beyond the limits of the bn^ast, is formed by the cancer-filled lymphatics of the fascial lymph-plexus, and lies, as a rule, exclusively in the plane of this plexus. As one ap- proaches the center of the lens, which center corresponds to the primary growth, the adjoining layers of tissue are invaded by cancer to a grad- ually increasing depth. However this may be, the surgeon in practice discovers clinically a mass in the breast and enlarged nodes in the axilla, but he may be sure that the region between the primary growth and the nodular metastases is itself the site of microscopic cancerous involve- ment. Cancer occurs in the male breast also, springing from the nidimen- • W. S. Handley, Glascow Med. Jour., December, 1905. CANCER OF THE BREAST 513 tary glandular epithelium. It is rare in men, though its exact frequency is somewhat undetermined. 1 have seen one male breast cancer in a group of 72 cancers of the breast. The figures usually given are 1 in 100. Surgical literature abounds in protest against the common conceal- ment of breast cancer practised by women, and it is hard to see why the victims of this disease so frecjuently attempt to keep all knowledge of it from their families and from their physicians even. We are coming to believe, however, that modem teaching and the insistence by our profession on the importance of early treatment are tending to abolish the old-time unhappy tradition of secrecy. Cancer of the breast was formerly regarded as a horror for which there was no hope. To-day we know that an increasing proportion of these cases are cured by operation. The symptoms of cancer of the breast are elusive often, rarely char- acteristic in the early stages of the disease, sometimes not obvious to the patient until the growth has developed far. The symptoms depend on the age of the patient, the location of the tumor, and the histologic nature of the growth. Unfortunately, the symptoms, of diverse char- acter, are never a sure indication of the exact nature of the growth, even though its malignancy be assured. We look for the following symptoms and signs: pain, tumor, dimpling of the skin, ulceration, re- traction of the nipple, involvement of lymph-nodes. The pain may be early and may be the first indication of trouble. It may be dull and boring, or it may be lancinating and shooting, or there may be a stitch in the side, running into the shoulder and upper arm. Or there may be no pain for long, but a tumor may be the first evidence of trouble. A woman, robust and vigorous, may consult the surgeon and state that she has discovered recently a painless lump in her breast. The surgeon must examine the lump with suspicion, no matter what the age of the patient, and he must not be misled if the lump be found in that detached portion of the gland lying high toward the axilla. A cancer, small and deeply placed, is always fixed in the breast; it is not encapsulated, and cannot be moved about. If deep, it may not be felt by the examining hand lifting the breast in front. The surgeon should stand behind the sitting patient, and with his hand over her shoulder should roll under his fingers the breast, flat- tened against the chest, when he will find an infiltrating mass pre- viously undetected. On the other hand, most cancers of the breast are easily palpable on the patient's first visit to the surgeon, and fre- quently the condition is only too apparent. As the disease advances the skin over the mass becomes pitted; later it breaks down in an ulceration; the nipple frequently retracts, and enlarged nodes in the axilla become apparent. An increasing cachexia accompanies those local signs of trouble. Appetite and strength fail, slowly at first, rapidly toward the end. There has been much discussion regarding the time in the progress of the disease at which enlargement of the lymph-nodes occurs. Older surgeons have gone so far as to assert that these nodular 33 514 THE CHEST metastases do not appear until the parent growth is a year old. Prob- ably this is not true. The time of appearance of enlarged nodes depends upon the character and rate of growth of the cancer. Mor(H)ver, one observer may discover euhirged nodes undetected by another. In order to find axillary nodes, sit before the patient, whose arm should be raised, and press your fingers high into the axilla, with the palm of your hand against her chest. Then bring the patient's arm down to her side. One may detect palpable nodes against the ribs and along the lo\\er margin of the pectoralis major. Late in the disease the cervical and clavicular nodes become involved. In the breast a single mass only can be felt, as a rule. Rarely two tumors are present, and the surgeon should never fail to examine the opposite breast also. In nearly 7 per cent, of the cases both breasts are involved. The surgeon founds his diagnosis upon the evidence of a tumor, pain, and involvement of lymph-nodes. The characteristic cachexia is a late symptom. In many cases one is in doubt as to the diagnosis, especially when the only evidence of disease is the tumor. In such case, no matter what the age of the patient or the character of the mass, the surgeon should be extremely cautious in pronouncing against cancer, and should give a favorable diagnosis of benign tumor only when such a diagnosis of benign growth is clear. If there be the least doubt, he should ex- plore the breast by the method of plastic resection which I shall describe, should have the tumor examined immediately, and should proceed with the radical operation if it prove to be malignant.^ It is a safe rule to remove all tumors of the breast in w^omen thirty-five or more years old. The prognosis of breast cancer unremoved is always positively bad, and the duration of the disease before death depends on the age of the patient and the nature of the cancer. Medullary cancer may kill a woman of forty in a year. A woman of seventy may live with a scirrhus for three or more years. The prognosis after operation I shall discuss in a later paragraj^h. The treatment of cancer of the breast is by radical operation. There is not the slightest evidence that other methods of treatment offer a hope of cure. Twenty-five years ago the profession was still convinced that removal of the tumor by operation was a desperate measure, but within the last fifteen years the results of such radical operators as Halsted, Joerss, Rotter, Cheyne, Warren, and many others have forced the con- viction that breast cancer taken early and thoroughly excised do€s not return. The statistics of permanent cures under the treatment of com- peteht surgeons vary all the way from 19 to 42 per cent. It is an in- teresting fact that local recurrences take place commonly in the scar or skin over the chest and not in the axilla. All reliable surgeons, with one or two exceptions, are now agreed that the dissection should be far- reaching and thorough, and should involve removal not only of the whole * I deprecate stronfjly the use of the exploratory punch sometimes advocated, since it may bring away portions of the cancerous mass, and cause the rapid in- volvement of overlying skin. CANCER OF THE BREAST 515 breast, but of its overlying skin, a wide zone of adjacent fat tissue, both pectoral muscles and the fat and nodes of the axilla. A routine attack upon the clavicular and cervical nodes seldom is advocated. The dis- section 1 have described implies an opcu-ation of great gravity — an opera- tion re(piiring time and care, involving considerable loss of blood, shock often, sometimes extensive plastic repair of the wound, a slow con- valescence, and more or less permanent crippling of the arm on the affected side. Such in general terms is the problem before the surgeon; and so wide a removal of tissue seems necessitated from our conviction that cancer involves parts beyond any obvious macroscopic lodgment, that its microscopic presence may be found in the skin, in the tymph-spaces, in the fat, and in the underlying aponeurosis and muscles. J. B.. Murphy alone of recognized authorities maintains that a removal of the pectoral muscles seldom is necessary, because the growth, when taken early, does not penetrate beyond the aponeuroses. Operation for Cancer of the Breast. — The radical operation for removal of breast cancer is the only operation seriously to be consid- ered if one anticipates a cure, though we may observe in passing that sometimes the surgeon dealing with hopelessly extensive cancer may think it best to do a palliative resection with the purpose merely of con- verting a foul, ulcerating area into a clean wound. Numerous radical operations in recent years have been devised, but all of them follow essentially the rules laid down by Halsted.^ The variations in detail from Halsted's technic aim merely at treating the axilla so as to pro- duce less impairment of the arm's function, and at attacking the mal- ignant mass at some novel point. For several years I followed that method of procedure to which Warren's^ name is attached. As Warren points out, we cannot observe anatomic landmarks or regard cosmetic effects when dealing with cancer, for cancer invades tissues indiscrimin- ately, and the surgeon with his knife in like manner must invade them if he hopes to extirpate the disease; he must remove the entire growth with a wide margin, cutting into muscle, skin, aponeurosis, bone, vas- cular and lymphatic connections wherever he has reason to suppose they are involved in the cancer. I used with satisfaction and for many years the following technic: Enter the knife at the shoulder and carry it down toward the outer border of the breast along the anterior axillary fold, and about two inches to the inner side of it at the start. Sweep around the outer and lower border of the breast at the circumference of that organ. Warren points out that at this stage, if the operator is in doubt as to the nature of the growth, he can turn up the breast from below and excise a portion of the tumor for microscopic examination. Having determined that the growth is malignant, the surgeon now com- pletes his sweep about the breast, and brings his cut up on the inner side to meet the original incision on a level with the axilla; he thus forms 1 W. S. Halsted. Ann. Surg., November, 1894. 2 J. C. Warren, The Operative Treatment of Cancer of the Breast, Ann. Surg., December, 1904. m THE CHEST a racket-shaped wound of great extent, the edges of which he will prob- ably be unable to bring together. Next, with a view to the ultimate closmg of the wound, he marks out a supplementary Hap low in the axilla, such as is shown in Fig. 327. In order to provide for a possible dissection of the cervical triangles he marks out also a third incision running into the neck. r Fig. 327. — Warren's operation for amputation of the breast — step 1. The second step in the operation is freely to turn back the skin on all sides and to dissect up the supi)lementary axillary flap. This dissec- tion should be carried high enough in the neck to expose the clavicle. One now sees an extensive wound, shaped somewhat like a tnuicated cone, the untouched breast representing the base, with a considerable expanse of fat and muscle tapering off toward the axilla. The third stage in the operation consists in removing entire the ex- posed suspicious tissues. Begin the deep dissection above, and turn CANCER OF THE BREAST 517 in the ^vholc mass toward the stcM-nal side. Strip up with the finger the insertion of the pectoralis major toward the humerus (leaving Fig. 328.— Warren's operation for amputation of the breast— step 2. Fig. 329.— Warren's operation for amputation of the breast— step 3. the clavicular portion), and cut away the muscle near the bone. Turn down the severed pectoraHs major and expose the insertion of the 518 THE CHEST pectoralis minor; cut this away close to the scapula. Ihon, by firni retraction downward and inward, the surgeon exposes readily the axilla. He clamps the larger arteries and veins and cuts them away close to the axillary vessels, after which, rapid dissection with the knife and fingers exposes the posterior muscles and the serratus. The deep nmscular at- tachments are now freed completely down to the ribs, when it is an easy matter to peel off by quick dissection the whole disease-mass toward the sternum, removing, as one goes, both pectoral muscles. After this a further cleaning of the parts high in the axilla may he done if needful, and a supplementary dissection of the cervical triangles through turn- J / Fig. 3.30. — Warren's operation for amputation of the. breast — step 4. ing back the neck flap as I have indicated. It remains to close in the great wound, Avhich can scarcely be done without utilizing the supple- mentary axillary flap. The figures show how easily and perfectly one may accomplish this, as a rule. I recommend draining the wound with a cigaret wick in the axilla for twenty-four hours. Extensive scar-formation in the axilla may follow this operation — scar-formation which cripples seriously the action of the arm. The surgeon should endeavor, so far as possible, to obviate this condition by tucking the lower skin-flap high into the axilla and securing it there with a buried stitch. In consideration of the possibility of trouble with the CANCER OF THE BREAST 519 urm Murphy ^ advocates certain muscle-plastic procedures which are interesting. He points out that undesirable results of removal of the breast as commonly done are: (1) Fixation of the arm to the chest, with more or less limitation of motion; (2) venous stasis in the arm and fore- arm with edema; (3) pseudoelephantiasis ; (4) neuralgia in the arm and forearm; (5) sensitive retracting scars. In order to forestall these cal- amities Murphy advises dressing the arm at a right angle to the chest and supporting it in a plaster splint during the early days of convalescence, and the interposing of muscle slips between the axillary vessels and the axillary skin. His arguments are ingenious and suggestive, and his methods appear feasible. He uses long and broad slips from the pector- alis major or latissimus dorsi. He justifies his use of the pectoralis major by asserting that its entire removal with the breast is needless, Fig. 331. — Warren's operation for amputation of the breast — step 5. " as the aponeurosis and not the muscle carries the lymphatics in which metastases occur." Most operators, while agreeing in part with Murphy in this contention, will protest that no man may say whether or not the pectoralis major muscle itself is involved in the disease. The use of the latissimus dorsi, however, seems free from this objection, and the ap- plication of the plaster bandage with the arm held out from the side promises much. On the other hand, the disabilities rehearsed by Murphy are not so common as he might lead us to suppose. Careful surgeons endeavor to fill in snugly the axillary gap after the dissection, and excel- lent function of the arm under the old methods is the rule. I find that, by the careful obliteration of dead spaces, by draining the axilla for twenty-four hours, by padding abundantly the axilla so as to hold the 1 J. B. Murphy, Axillary and Pectoral Cicatrices Following the Removal of the Breast, Axillary Glands, etc., New York Med. Jour., January 6, 1906. 520 THI-: CHEST arm well out from the side, and by the curly use of passive movements I encounter rarely those disabilities which have been mentioned. The (iftcr-trcattucnt and a long-continued following up of these cases are important. One should get the patients out of bed at the end of a week — not earlier, because early moving about may dislodge a thrombus, with a fatal result, as in one of A^'arren's reported cases. In the second week of convalescence one should begin passive movements and massage, and kee]) up this treatment persistently for a month or long(!r. After the patient's health has been restored, she should make periodic visits to the surgeon for at least three years, that he may inspect the scar to discover possible recurrence of the disease. At the same time he should investigate the patient's spine, lungs, and other viscera. Nothing can be done with the knife for internal metastases, but local recurrence often may be treated by excision. The outlook after such thorough removal ■■j^^cJ**?^'- /?^^>/i<£Jr/^ Fig. 332. — Line of incision for brea.st operation (Jackson'.s method). of breast cancer is increasingly favorable, as I have said, and in direct proportion to the prom])tness and early date of the operation. I have described in detail the steps of Warren's operation, pointing out that its principles coincide with those of all radical operations on the breast. Sundry other incisions and steps are advocated by other writers. Halsted's classic and pioneer work is not to be forgotten. His incision essentially is followed by Warren, but Halsted turns out the dissected mass toward the axilla instead of inward toward the ster- num. Kocher advocates an interesting incision the outlines of which suggest a reversed figure 6. ^^'illy Meyer * long ago described and advo- cated an operation similar to that I have given in detail, and Jackson - 1 Jour. Amer. Med. Assoc. July 29, 1905. 2 Jabez N. Jackson, ibid., March .3, 1906. CANCEll OF THE UUEAST 521 Fig. 333. — External appearance of cancer of breast. Removed by Jackson's method (personal case). Fig. 334. — Operation for cancer of the breast; shows pectoralis major muscle (per- sonal case). describes an interesting incision which I have now adopted ; but it is needless further to enumerate the countless modifications and sugges- tions upon this subject by recent writers. 522 THE CHEST In spite of tho improvement in our statistics surgeons have not rested content with the results of radical breast operations, and numerous and carefully conducted investigations on other lines of treatment con- stantly are being made. So far such endeavors have accomplished little. The a:-rays, violet rays, and radium are nearly valueless, though they may relieve pain; and the much-vaunted trypsin injections of Beard are not making good the claims of their original advocate. A few j'ears ago Beatson's operation^ seemed to promise something. Beatson's opera- tion consists in removing the ovaries for the supposed effect which the loss of those organs has upon the epithelial cells in the breast. Al- though a few cases of notable improvement in breast cancer following Beatson's operation have been reported, the number of successes by this method arc too few to warrant confidence in the jjiocedure. ctcil f personal case). AMiile cancer is that form of breast timior most interesting and im- portant because of its frequency and fatality, numerous other new- growths are to be found in the breast, some of them benign, some of them doubtful, some of them truly malignant. Fibroma is a common tumor of the benign class; sarcoma is a somewhat rare tumor of the malignant class. Most of these non-cancerous tumors are allied to each other in structure and origin, so that a brief consideration of the whole class simis up for us our knowledge of breast tumors other than cancer. In a previous paragraph I spoke of a characteristic myxomatous connective tissue which develops about the terminal ducts and acini of the normal breast, it is with this periductal connective tissue that we ^ Jour. Amer. Med. Assoc, editorial, September 2, 1905. CANCER OF THE I?i;EA,ST 523 have to deal when we consider benign breast tumors, and I avail myself of J. C. Warren's admirable classification, to which I have already refcrretl. Warren points out that, owing to the intimate association of the periductal tissue with the epithelium lining the ducts, all tumors of the mammary gland contain some of the elements and take on some ot the characteristics of both connective-tissue and epithelial growths. Fig. 336. — Large cancer of breast (personal case). External appearance of breast after removal (reduced). Length, 13 in.; width, 10^ in. Bloodgoocl ^ also deals at length with this subject in an illuminating article. Warren gives the following table of breast tumors: " Carcinoma (already considered). Fibro-epithelial tumors : (1) Fibrous type: 1. Periductal fibroma. 2. Periductal myxoma. 3. Periductal sarcoma. (2) Epithelial type (cystadenoma) : 1. Fibrocystadenoma. 2. Papillary cystadenoma. Hyperplasia: 1. Diffuse hypertrophy. 2. Abnormal involution. Cystic. Proliferative. 1 J. C. Bloodgood, Senile Parenchymatous Hypertrophy of Female Breasts, Its Relation to Cyst Formation and Carcinoma, Surg., Gyn., Obstet., December, 1906. 524 THE CHEST Chronic inflammation: 1. Eczoma of nipple. 2. Chronic abscess. 3. Ductal mastitis. 4. Tubcrculosi.s. 5. Single retention cyst. Non-indigenous tumors: 1. Sarcoma. 2. Lipoma. •i. Lympiiangioma. Supernumerary breast." Periductal fibromata, myxomata, and sarcomata all are closely allied, and one must observe the fact that the " chief constituent of the tumors of the fibrous type is the peculiar, transparent, periductal tissue of the female breast." We may reserve the name " adeno-' for those tumors in which the epithelial elements play the important part. Cystic dilatation of the ducts or of the characteristic clefts of the peri- ductal fibroma may occur, and is probably due to the obstruction of preexisting ducts. The cysts thus formed are, therefore, secondary; and the tumors may be divided, according to their richness in cells or the character of their fibrous tissue, into the three groups, fibroma, myxoma, and sarcoma. OTHER BREAST TUMORS Periductal fibromata of the breast (intracanalicular papillary fibromaj are encapsulated tumors, varying in size from a bean to a cocoanut. They are single or multiple; sometimes they contain cysts. They are firm, white, and glistening in appearance on section. Com- monly they are found in women between twenty and thirty years of age. The}' grow slowly; generally they are painless, though they may be sensitive at the menstrual period, and most frequently they lie in the upper outer quadrant of the breast . Periductal myxomata differ little in their structure from the fibromata. AYe assign them to a special group because they appear larger, as a rule, and are composed of a myxomatous fibrous tissue, identified by a local edema. They are tumors of middle-aged women; are almost always hard; sometimes necrotic; sometimes associated with enlargement of the axillary nodes. Nearly always containing cyst cavities, they differ from the previous class in no important respect. Periductal sarcomata constitute the third group of periductal tu- mors, and present the combination of a richly cellular stroma mingled with epithelial gland-ducts. These are large tumors; hard, often in- volving the whole breast, and reaching the size of a child's head. They are lobulated and encapsulated; often they contain cysts, and frequently they are ulcerated. The overlying skin is reddened and is traversed by dilated veins, but it is not always adherent. Rarely the axillary' nodes are involved. These sarcomata are most common in middle-aged married women, and cause discomfort from their size rather than from pain. OTHER BUr-^AST TUMORS 525 The treatment of these three types of tumor is obvious. Fibromata and myxomata demand local removal of the growth only, while the sarcomata require, in addition, amputation of the breast and dissection of the axilla. So much for fibro-epithelial tumors of the fibrous type. There is another class belonging to the fibro-epithelial group, however, characterized by a conspicuous development of the epithelial or duct elements in the breast. This is the — Epithelial Type {C ystadenomata) . — These tumors are benign, as a rule, though they belong to the epithelial type. Warren describes them as adenomata (fibrocystadenomata and papillary cystadenomata), and their name describes graphically their structure; they are not especially common. Fig. 337. — Periductal myxoma (W. P. Graves). Fibrocystadenomata are made up of periductal fibrous tumors con- taining secondary epithelial new-growths.^ They occur usually in young single women. They grow slowly and cause little pain. In ex- tent they vary from the size of a walnut to that of a fist. They are lobular, hard, and movable. The axillary nodes are not involved. They are encapsulated and show a lobular structure containing cysts of vari- ious sizes, the cj^sts showing papillary outgrowths of connective tissue covered with epithelium. The gland-ducts rather than the acini are involved. We must regard these fibrocystadenomata as approaching the 1 These are tumors variously described as adenomata, papillary cystadenomata, cystadenoma proliferens, polycystoma, cystic fibroma, tubular adenoma, etc. 526 THE CHEST border-line of malignancy. Ordinarily, it suffices to remove them by a small local incision, but the histology of each tumor must be studied carefully, for there is always a possibility of its developing late into carcinoma. Papillary cystadenomata constitute the second group of fibro-epi- thelial tumors. They are not common, but have distinct clinical and histologic characteristics. J.ike the periductal sarcomata, they occur commonly in midtUe-aged married women; they are of slow growth and long duration, antl while not very troublesome and causing little pain, their characteristic symptom is the discharge of a bloody fluid A** ■■'■J '/0 \ Fig. 338. — Diffuse mammary hypertrophy and prejinancy (Massachusetts General Hospital). from the nipple. In consistency they are hard usually, though occasion- ally one may detect fluctuation; rarely is there involvement of the skin and axillary nodes. This timior is most often foimd close beneath the nipple. If you examine the excised specimen, you will find, on section, a cyst cavity containing a bloody fluid, the walls of the cj'st lined with papillary or villous outgrowths composed of connective tissue sur- rounded abundantly by epithelium of the ductal rather than the acinal cells. In the case of small papillaiy cystadenomata, I'esection generally suffices for a cure, but when the tumor is of considerable size, of long OTHER BUKAST TUMORS 527 Standing, and cspecialiv if the axilla be involved, one should do a total dissection of the breast and axilla. Such operations give every hope of a pornianent cure, but the surgeon should remember that tumors of this type frequently become malignant when left untreated. There is another class of benign breast enlargements which should not properly be grouped with the neoplasms I have just described, i mean those diffuse enlargements of the breast to which we apply the term " hyperplasia." This term signifies an increase m both the fibrous and epithelial elements, and may affect one or many lobules. ^ arren divides " hyperplasia" into two divisions: (1) Diffuse hypertrophy and (2) abnormal involution.^ Fig. 339.— Plastic resection of the breast, line of incision— step 1. Diffuse hypertrophy is a rare condition which may be found in women of all ages, especially before the menopause. One or both breasts may be affected, and the growths may reach an enormous size, so that their amputation to relieve the patient of their weight may be neces- ^^"^ Abnormal involution (senile parenchymatous hypertrophjO is a more common and more serious matter, and the important fact about it to be borne in mind is that it has a benign and a malignant stap. V\ hen it is found in the malignant stage, it must be treated by radical operation. In the benign stage, however, one finds two types of senile hypertrophy, 1 This is the condition admirably described by Bloodgood under the term "senile , , , „^^^r,u^r " Thin iq the chronic mterstitial mastitis oi zim parenchymatous hypertrophy. ilns is y?5./^™ V,, . x, j^j-onic mastitis or Fnalish writers- the chronic cirrhosmg mastitis of Billroth, tne cnromc "3'^*^., jKefibr" adenoma of Wood; the cystic d^ease of the breast of Bryant, the fibrous hyperplasia with retention cysts of W. F. ^^ hitney etat. 528 THE CHEST the cystic and the adenocystic. In the cystic type the fibrous thickening has produced dilatation of the ducts alone. In the adenocystic tyj^e the cysts are present also, but in addition there are proliferative changes in their epithelium. Women in middle or advanced life are the subjects of abnormal in- volution. In many cases of both the cystic and adenocystic forms, both breasts are involved, though usually to a different degree, and the masses may present diffu.se or local hardenings. A hardening may bo firm and nodular, or soft and even fluctuant. In a great many cases there are pain and tenderness; in a few there are enlarged axillary nodes; frequently there is inversion of the nipple. In most cases the Fig. 3-40. — Plastic resection of the breast — step 2. Breast turned over and tumor exposed by triangular incision. process is diffuse; rarely one lobule of the gland alone is affected, sug- gesting an encapsulated tumor. The microscope shows fibrous hyper- plasia and secondary involvement of the gland stiiicture, with cyst formation. In the adenocystic type of abnormal involution one may distinguish three groups, depending on the character or degree of the epithelial growth, as follows: (1) Proliferation of the acini; (2) papillary outgrowths of epithelium into cysts, and (3) adenomatous proliferation of epithelium. The first and second of these may possibly develop into carcinoma, while adenomatous proliferation is especially interesting, from the fact that in its presence chiefly we find the combination of invo- lution and cancer. The reader will see. therefore, that these cases of senile hypertrophy are of striking and anxious importance. At first, on MASTITIS 529 examininfr thorn, no man can say whether or not they are mahgnant. For this reason, whenever one finds induration in the breast of a woman at the menopause or later, he should operate. He may do a plastic resection and remove the growth for immediate examination, and he maj' do a complete radical operation if it seems indicated. The operation of phistic resection is simple, easy, and causes little or no disfigurement. The surgeon enters his knife at the periphery of the breast high in the anterior axillary line, and sweeps it down around the breast so as to take in one-half to two-thirds of the gland's circum- ference. He then dissects rapidly down to the aponeurosis of the underlying muscle and turns the breast up, when he may attack from below and remove tumors and other suspicious thickenings, as I have indicated in the accompanying figures adapted from Warren's paper. Fig. 341. — Plastic resection of the breast — step 3. After excising the masses he closes with buried absorbable stitches the gap in the gland and replaces the breast ; or, if necessary, he may proceed to the complete radical operation. The wound heals rapidly and kindly and a slight scar only remains. The simple plastic resection may be dressed with an empire bandage, and the convalescence should not last more than ten days. So much for our discussion of tumors of the breast, malignant and benign. MASTITIS Acute mastitis with abscess is that affection of the breast gland which next, after cancer, is most interesting to the physician, but as .34 530 THE CHEST this is a disease which concerns obstetricians especially, wo need say little of it here. It is an inllaniniation of the nipj)le and breast ducts and is due directly to an infection in nursing women. One wonders perhaps that all women during lactation do not suffer from acute mas- titis. The essentials for the setting up of such an inflammation are some slight crack or al^rasion in the nipple, giving lodgment to infecting or- ganisms, and a milk-]:)r()ducing breast which is imperfectly drained. Nurses speak of "caked breasts," by which we understand a backing up and stagnation of milk in the acini and ducts. If infecting bacteria reach these deeper parts, they set up readily an irritation to which the organism responds with the production of hyperemia, inflammation, and pus; as the infection progresses the breast elements break down, and shortly there is produced a considerable area of suppuration; indeed, the whole breast may become involved. When one examines a woman suffering from breast abscess, he finds her more or less prostrated with fever, with a rapid pulse and great pain in the breast, which looks dis- tended, red, and glossy, varying in consistency, in one place exquisitely tender and fluctuant, elsewhere less tender, but hard and brawny. The treatment of such infected breasts consists in stopping the in- fant's nursing, supporting the breast in a firm bandage with an ice-cap, and, in the early stages, applying massage to evacuate the milk. At the same time copious movements of the bowels should be obtained by the use of salts. When an abscess has formed, it should be opened thor- oughly by incisions radiating outward from the nipple, but the cut should not involve the areola. This operation frequently leaves a badly scarred and deformed breast. Another method of operating — a method effective and less deforming, is to turn up the breast from below, as in the plastic resection operation. The abscess may then be opened at its base and drained after the breast has been replaced in position. Throughout the patient's convalescence the breast should be supported by comfortable bandages, and the abscess cavity should be irrigated daily. These patients, like so many others afflicted with local infec- tions, may be helped greatly by appropriate opsonic injections. Chronic infections of the breast are far less frequent than the acute infections, and may be divided into two classes — infections con- nected with lactation, and such specific infections as those due to the organisms of tuberculosis and syphilis. The much-abused term "chronic mastitis " should be applied to the lactation inflammation only. Chronic mastitis may be found in women toward the end of lactation, and appears as small multiple abscesses and necrotic foci distributed in close relation with the deeper ducts throughout the breast. These foci appear as tender, indurated masses and may be adherent to the skin, while the axillary nodes may be enlarged. There is an increased amount of fibrous tissue also, while the periductal tissue is infiltrated with small round-cells and leukocytes. The striking clinical characteristic is an irregular, extensive induration of the breast occurring shortly after lactation and affecting 3'oung mothers especially. Surgical treatment alone is effective. MASTITIS 531 Paget's disease of the nipple (ni:ili<2;nant dermatitis) is an infection of cl{)iil)tt'ul (>ti()l{)gy aiul natur(>. It consists in a chronic inflammation of the epithehal hxyer of the nipple and areola. It occurs usually in women beyond middle life, and frequently advances to epithelioma of the nii)p]e and to duct cancer. It is not a simple eczema. The affected portion appears raw and red; from it there exudes a yellow discharge, and the disease may extend superficially over much of the gland. The axillary region becomes affected. When the surgeon has determined that local applications are useless, he should proceed with the knife thoroughly to extirpate the disease. This may involve radical removal of the breast with dissection of the axilla. By galactocele we mean a breast retention cyst, the contents of which are of a milky character. If these cysts do not become infected, the harmless, neutral, milky fluid may remain indefinitely. Frequently one may relieve the patient by aspirating the cyst and strapping the breast. The important specific inflammations of the breast are due to tuber- culosis, actinomycosis, and syphilis. Tuberculous disease of the breast is rare, and more rare in men than in women. The victims are usually between fifteen and thirty years of age, and are wont to show evidence of tuberculosis elsewhere. The disease manifests itself variously — sometimes as a cold abscess in the breast; sometimes there are isolated caseous nodules, and this form is the most common ; sometimes the disease starts as an ulceration in the region of the nipple. The cold abscess may remain indefinitely; caseous nodules may break down and cause ulceration, with the form- ation of sinuses; superficial ulceration may spread, while in all forms the axillary nodes may be affected. If the patient's condition is fair and extensive tuberculosis be not present elsewhere, the surgeon should amputate the breast and remove thoroughly all suspicious foci. A few cases of actinomycosis of the breast have been reported. Like actinomycosis elsewhere, this is a chronic destructive process which goes on burrowing, forming abscesses and sinuses. To establish the diagnosis one must discover the characteristic fungus in the discharges. Total removal of the breast generally will destroy the disease, and prom- ising results have been obtained by the use of copper salts after Bevan's fashion, which I described in dealing with abdominal actinomycosis. Manifestations of syphilis of the breast are extremely rare and occur as gummatous mastitis late in the course of a syphilis. The lesions are circumscribed and may suggest cancer to the examiner. So uncommon is the condition that the true diagnosis probably will not occur to the surgeon. However, if syphilis is suspected, he should prescribe anti- syphilitic remedies, and give them a trial for at least three weeks be- fore attempting any operation. Should the diagnosis of syphilis be confirmed, he should do no operation. Echinococcus of the mammary gland is uncommon; it should be treated by incision and removal of the sac-wall. 532 THE CHEST Besides such inflammatory diseases, there are a few additional breast lesions which deserve mention. RETENTION CYSTS Single retention cysts occasionall}- are found in the breast, and are of the same general character as those produced by the occlusion of a duct in other glandular structures. These cysts occur at any age after the development of the breast, and appear as isolated, painless, clastic, fluctuant tumors, in size varying from a walnut to a hen's egg, and of uniform and rapid growth. They should be enucleated either through a direct incision or by plastic resection. Authors mention sundry other tumors of the breast which are desig- nated non-indigenous — that is to say, they are situated in the breast accidentally, as it were, and have no special relation to the peculiar mammary gland structure as regards their origin. Such tumors are lipomata, lymphangiomata, enchondromata, and certain rare fibromata and sarcomata. Their treatment differs in no wise from that of similar tumors found elsewhere. SUPERNUMERARY BREASTS AND NIPPLES Supernumerary breasts and nipples occasionally are seen, but as they have no special tendenc}' to disease, they deserve no special mention except that they are found in that so-called "milk line'' extending from the clavicle to the groin. One sees, therefore, that diseases of the breast are various and interesting. No other single gland in the body is of equal surgical im- portance; and upon it the activities of pathologists have concentrated themselves until study of the breast has become almost a specialty in itself. PART V THE FACE AND NECK CHAPTER XX HARELIP AND CLEFT-PALATE We now come to the consideration of another ancient field of surgery. The earliest of medical writings describe superficial congenital abnor- malities, and such abnormalities have been made the study of surgeons since remote times, with the result that an enormous literature upon the subject has been compiled. Yet it is within the last one hundred and fifty years only that satisfactory explanations of, and operations for, these lesions have been formulated. A variety of clefts and mal- Fio;. 3-' 2. — Single harelip and cleft-palate. Fig. 343.— Double harelip. formations of the face are described, but most of them are rare, nor, with the exception of harelip and cleft-palate, do they come within the e very-day experience of practitioners. All these cleft formations result from an arrest or disturbance of development in early fetal life, as a glance at the face of a month-old embryo will show. We are apt to think of deformed lips as the only types of cleft to be considered, but surgical literature and every anatomic museum demonstrate extensive clefts and deformities not only of the lips, but of the nose, cheeks, fore- .=S33 534 THE FACE AND NECK head, eyes, and ears. It is needless here to detail the curiosities. Fre- quently they can be repaired and improved, and 1 refer the student to larger works on the subject for a discussion of their characteristics and treatment. HARELIP Hureli}), however, is a coninion deformity, and has been dealt with by such distinguished writers as Lemonier (1776), Eustache (1779), John C. Warren (1S20), and in more recent times by von Graefe, Roux, G. V. I. Brown, J, Collins ^^'arrcn. and numerous others. The lower lip rarely is cleft; the vast majority of clefts are found in the upper lip, and these clefts or harelips are of three main varieties: (1) A notch in the vermilion border; (2) a deep notch extending nearly to the nares; (3) a cleft dividing completely the upper lip and penetrating the nasal canal. Harelip of all varieties may be single or double, and single harelip is ^:::^E:=> Fig. 344. — Double harelip and cleft-palate. Fig. 345. — One-month embryo (magnified). more common on the left side than on the right. All forms of harelip — especially complete clefts into the nares and double harelip — may be associated with cleft-palate, but we are considering here harelip only. Double harelip may present two simple fissures into the nostrils, with a bit of normal looking jaw and lip between them (a normally placed in- termaxillary bone) or the intermaxillary bone may be thrust foi-U'ard prominently so as almost to resemble a small proboscis protruding beneath the nose — a type of deformity in the highest degree disgusting and unsightly, and the physician who has the misfortune to attend in confinement a woman giving birth to an infant thus marked will never forget his ovm. distress and peiplexity on seeing the child's face, and the horror and shock of the parents. The diagnosis of harelip is instantly obvious, but the symptoms and the disturbance to the infant develop gradually. Suckling is diffi- HARK LIP " 535 cult or impossible; mouth-breathing is the rule, with an inevitable foul- ing of the buccal and nasal cavities and an occasional consequent bron- chitis or pneumonia. These infants fail to get proper nourishment unless they have special care. As a result of such disadvantages harelip babies arc proverbially feeble and rachitic — a condition not due necessarily to an inherent weakness or taint, but to lack of sufficient and proper food. The treatment of harelip divides itself, therefore, into two parts — the feeding and sustaining of the infant and the repair of the deformity.' If the attending physician is not skilled in the problems of infant-feed- ing, he should consult an infant's specialist immediately after the baby's birth. Proper treatment consists in supplying the child with a normal amount of an accurately prepared cream mixture, plenty of water to drink, keeping the bowels properly open, cleansing the mouth thoroughly after each feeding, and feeding by means of a dropper, while the child is Fig. 346. — Simplest form of liarelip. Fig. 347. — Single notch of lip. held in the semiprone position. I believe in giving a little brandy as a stimulant for a week before operating. The time for operating on harelip is in the sixth or seventh week of life, as a rule. By this time the baby will have begun to react well after birth and to flourish, its digestive processes and heart and lung action being ready for the strain of the operation. I regard ether as a safe and satisfactory anesthetic. There is no need of keeping the child constantly under its influence during the operation, but one may allow the patient partially to come out from the anesthetic and to cry from time to time. The air-passages are thus cleared and the surgeon feels reassured. The child, tighth- swathed in a sheet, should be held upright in the arms of an attendant, behind whose shoulder stands the etherizer with his cone, while the surgeon sits in front of the patient. The tj^es of hare- lip operations are many, but the good operations are all much of a kind. In a word, a good harelip operation involves loosening with 1 J. G. Mumford, Medical and Surgical Treatment of Harelip, Boston Med. and Surg. Jour., March 3, 1S98. 536 THE FACE AXD NECK blunt-pointed scissors the cheek from the upper jaw, so as to dimin- ish subsequent traction, carefully trimming and adjusting with the knife the wound-edges to be sewed and everting downward a mar- ginal flap so as to obviate the puckered notch which comes with the contracting scar of a badly done operation. There is a familiar and abominable operation, which consists in slashing with scissors the Fig. 348. — Infant hold in position for harelip operation. edges of the cleft, so as to transform it into a raw inverted V, and sewing it up with through-and-through stitches. Invariably there results an ugly notched lip. The text-books tell of the operations of Nelaton, Malgaigne, Mirault, von Langenbeck, Simon, and a dozen others. Nelaton's operation is applied to single notches. The required cuts are made through the lip above the notch with no sacrifice of tissue. HARELIP 537 When the ends of the cuts are brought together the notch is converted into a nipple, the principle of the operation being similar to that of the Heineke-Mikulicz pyloroplasty. If the cleft in the lip be single and reach nearly to the nostril, it is necessary to sacrifice some tissue. But names and descriptions count for little; the accompanying diagrams show best how these operations may be done. Double harelip is far more difficult to close successfully and properly than is the single harelip. The following description of the technic with modifications may be applied to harelip operations of all sorts, and the surgeon should remember that no routine fits all cases. How shall one dispose of the intermaxillary bonef If the bone be not greatly displaced, and if it be readily pushed back and held in posi- tion beneath the nasal septum, one may proceed immediately with his Fig. 349. — Intermaxillary bone. plastic work. Occasionally, however, the intermaxillary bone cannot be pushed into good position, and upon this we are confronted with a conflict of authority. Some conservative surgeons assure us that the intermaxillary bone must be preserved at all costs, either by fracturing it and crowding it down or by sHcing out a V-shaped bit from the vomer, and thus allowing room for replacement of the intermaxillary. Other surgeons excise the obtrusive bone from its mucocutaneous envelop. They point out that the intermaxillary bone is useless and fails to develop when crowded back, and that the incisor teeth which it bears are mdi- mentary and short lived. When the bone is removed, a gap is left in the alveolar line which must be filled by a plate or other dental apparatus. I advise removing troublesome intermaxillaries. Then in detail one may proceed as follows: an assistant on either side seizes the edges of the lip and holds them forward, at the same time controlling hemor- 538 THE KACE AND NECK rhage by pressure. The surgeon, using blunt-pointed scissors, then dis- sects up the cheek on either side of the alac of the nose, hugging closely the bone, so as to avoid hemorrhage. He then refreshes the edges of Fig. 350. — Looseniiii? the clicck. mucosa about the intermaxillary, working with a small sharp-pointed knife; he trims off the edges of the larger flaps, leaving at either angle tabs which may be brought dow'n and out to form the required nipple- Fig. 3.51. — Drop silver stitch. Fig. 3.52. -Final suporficial stitoli place. like projection which shall preserve properly the line of the up])er lij). He places one deep and important stitch high, jnissing from sulcus to sulcus of the alaj nasi. Remember that the nostrils generally are flattened HARELIP 5.39 by the existiufi; deformity, and lliat this deeply placed stitch, preferably of siKcr and sliollcd, acts as a strong stay to hold closely th(! wide margin of the wound and to build up properly the ala> and tip of the nose. The placing of this deep silver stitch is somewhat difficult and is important. The rest of the operation is now easy and obvious. I complete the sew- ing up, using silk sutures thi'eaded at either end into fine round cambric needles. These sutures do not take in the skin, liut are passed through the subcutaneous tissues and mucosa from without inward, and are tied inside the mouth, the ends being left long. Practically this completes the operation; but if a slight gaphig skin-line remains, one may close it with a few superficial intestinal stitches to be removed on the third day. Stitch abscess and ugly scars are obviated by this method of sewing. By no means the least important part of the operation is the dressing of the wound, which implies a supporting strap from cheek to cheek to take off traction from the line of incision. I use commonly a crepe de lisse butterfly, drawn tightly and fastened with collodion. "^^ Fig. 353. — Sketch showing dressing completed. Taylor^ recommends the device shown in the illustration. It seems reasonable and useful. The after-care of these cases is delicate and Important. The opera- tion causes a certain amount of shock, and the baby swallows a certain amount of blood. As a result there is usually some gastro-intestinal disturbance and imperfect assimilation of food for a time; so the after- care resolves itself into general treatment and special dressings of the wounded mouth. Six hours after the operation give the baby a dram of olive oil to clear out the bowels, and begin carefully with artificial feeding. After each feeding the mouth, tongue, lips, and nostrils should be wiped out thoroughly with a cotton stick dipped in boric acid (4 per cent.). All these operations are necessarily somewhat septic, so that one cannot expect perfect primary union in ever}^ case, but the lips of healthy children heal quite readily, and even if there be some gaping of the upper part of the wound beneath the nose, the lower part and ver- ^ Alfred S. Taylor, A Dressing after Harelip Operation, Jour. Amer. Med. Assoc, vol. xlvii. 540 THE FACE AND NECK milion border ncarl}' ahvays hold. If the veiniilion border alone re- mains sound, one is justified in looking for eventual healing by second intention, and this is aided by careful strapping. By the end of two weeks the union should be so sound that all apparatus may be discarded. Fipj. 354. — Taylor's dressing complfted. If harelip operations be done properly and deftly, the improvement in the infant's appearance is remarkable, and few operations upon chil- dren gain so instantly the enthusiastic gratitude of parents. CLEFT-PALATE Cleft-palate often is associated with harelip, and demands our study in connection with it. A cleft may divide the soft palate only or may penetrate through the bony palate to the opening of the nostrils; and when the bony palate is cleft, the soft palate is always involved. Some- times the cleft may be at one side, passing either to the right or left of the vomer, but more commonly the opening is in the middle line, with the vomer hanging free above it. Other peculiarities in the formation of the upper jaw are associated with cleft palate. The arch of the palate is abnormally high, so that the palate appears like a high-pitched roof when looked at from below — the cleft being substituted for the ridge pole, while the cavities of the nose and mouth form a continuous whole. These skeletal imperfections are generally associated with harelip, CLEFT-PALATE 541 though harch'p alone, without cleft-palate, is common enough. I have noted the functional (.listurbances resulting from harelip, and one sees at once how much more serious must be the disturbances when cleft- palate is added to harelip. Suckling is impossible, and malnutrition is a common result. As the child grows the lack of proper incisor teeth is a disadvantage, while serious defects of speech develop later — defects which can never be overcome through operation or apparatus when once the bad habits are formed. Moreover, with the cleft open, particles of food become lodged in the nares and set up troublesome or foul catarrhs and spreading infections. One sees then the imperative need of treat- ment. Treatment. — Not long ago there were two vigorously opposed opinions on this subject. Some men claimed the greatest benefit from obturators — plates devised by dentists for filling in the clefts in the hard and soft palates. Other men protested that the deformity could be repaired properly by operation. It is needless here to discuss the merits of this rather ancient controversy further than to state that although obturators have been of undoubted benefit in many cases, especially in adult cases, still to-day improvements in technic have convinced surgeons that an operation is best for young and vigorous patients. In spite of our confidence and conviction, however, one cannot be cer- tain always of obtaining satisfactory speech or perfect cosmetic results. The cases are not numerous in the hands of any one man, but there are a few dental surgeons, in this country especially, who have greatly im- proved the operation. Students of the subject recognize that the association of harelip and cleft-palate necessitates the treatment of both conditions as a patho- logic unit, bearing in mind always that the deformity is evidence of developmental failure in utero, and that these children must be regarded as degenerates with unstable nervous systems. For this reason, if for no other, the surgeon should take every precaution to prevent shock, and should operate at as late a time as possible consistent with the preservation of the speech function. In these cases then, and in simple harelip cases as well, one should begin, as soon as the child is bom, by gentle means to draw together the parts. Assuming that a competent surgeon has in charge the child from its birth until the entire deformity is remedied, he should apply at once and have reapplied daily from cheek to cheek a strip of zinc oxid ad- hesive plaster. This bridges the labial cleft, hides the deformity, brings nearer together gradually both soft and hard parts, — for the palate cleft can be narrowed by such means, — and prepares them the better for sub- sequent operations. Thiersch favors a composite strap — a plaster — into the middle portion of which is set an elastic band to lie across the open- ing in the lip and the protruding intermaxillary. The elastic insert exerts a constant contracting force at the same time that it gradually crowds back the intermaxillary. For the first six weeks the surgeon should take every pains that the infant be properly nourished and brought into condition for operation. Then in the middle of the second month 542 THr<: FACE AND XKCK he should repair the haroHp. Kepair of the cleft -])alate should not be done at this time under any circumstances. Some operators in the past have advised that the cleft-palate be repaired first, but e\])erience has shown that little Is gained by this measure as compared with the ad- vantages secured by restoring first the lip. l-'urtherniorc, the opera- Fig. 3.5.5. — Brown's compression apparatus. tion for cleft-palate is severe and the infant mortality after it is high. Besides this, cleft-palate operations on young babies are extremely difficult, owing to the delicacy of the parts with which the surgeon must deal. #■■' i..i t^ Fig. 356. - I-illchn. -u\'fr ili-^c t'i;^. 3.57. — I'illchrown's dissection of j)alutal mucosa. The restored lip exerts some slight compressing action upon the divided maxillary bones, but this is not by any means enough, so that it is advisable to employ some more effective compression apparatus for the six months preceding operation upon the palate. So long as the infant's molar teeth remain unerupted, the best means of compression CLEKT-PALATE 543 is that I have ah'oady suggested, b}^ a strap from cheek to cheek across the Hp; but after the eruption of the molar teeth, they can be used as bases on which to fix a contracting screw/ This device exerts traction so effectively that In' the end of a few months the cleft is materially diminished in width, and by so much is the operation rendered easier. AYhen the healthy child is well advanced in its second 3'ear, the surgeon proceeds to the — Operation for Cleft-palate.— The child is brought to the end of the operating table and the head is depressed in the position of Rose: the mouth is held open by a strong, well-fitting gag, and the whole cavity with the nostrils is swabbed out thoroughly with 70 per cent, alcohol, followed by boric acid. These fluids with accumulating blood are not swallowed or inhaled, but can be wiped away readily. The surgeon had best employ ether anesthesia, which may be administered in the or- dinary fashion, but is well given through a nasal or mouth tube after the method of Crile or Fillebrown.- The surgeon must use small in- struments—knives, scissors, vulsella, catch-forceps, periosteum retrac- tors, and elevator, and a variety of curved needles with a needle-holder. Employ for sewing up fine silver wire and silk sutures, and make use of small silver discs, about the size of a gold dollar cut square, as supports for the quilted stitches. Following Fillebrown, in closing the hard palate cleft, I have given up the Langenbeck method of splitting away the mucosa parallel with and close to the alveolar processes; I recommend the following procedure: turn back from the cleft on either side and close to the opening an abundant flap of mucosa, and peel it off from the bone nearly to the alveolar process. Refresh the edges of the flaps or, preferably, split them for about i inch in, and bring thepi together wdth three or four silver stay sutures quilted over the silver discs. This leaves loose flapping edges, which may be joined accurately, without tension, by interrupted silk stitches. Thus one has completed the repair of the hard palate, while the two halves of the soft palate remain flapping. Frequently it is well to postpone for a time the operation on the soft palate, waiting until the first wound has healed and the child has re- covered his vigor. Repair of the soft palate is not altogether simple, whether the cleft be original and uncompHcated, or be left over after the hard-palate opera- tion. Earlier operators began by loosening up the flaps, cutting the tensor muscles of the palate and the pillars of the fauces. This^ is a needlessly mutilating performance, and leaves the repaired palate m_ so functionless a condition that correct speech thereafter is almost im- possible. To relieve the tension on the soft palate it suffices to make lateral incisions external to the tonsils, and to dissect up the tissues 1 J. D. V. Singlev, Amer. Med., Sept-ember 16, 1905. 2 Fillebrown described his apparatus in 189.3: it is on the plan of the ' Junker system " It consists of a bellows, a wash-bottle containing ether, and a tube reach- ing to the patient's mouth. Air is blown over the ether in the bottle, and becoming charged with ether vapor, is led into the patient's nares or mouth by means ot the tube. 544 THE FACE AND XKCK with a blunt instrument, so as to avoid hemorrhage. Thus one forms lateral buttonholes which relieve sufficiently tlie tension. The flapping halves of the soft palate may then be refreshed at their edges, and brought easil)^ together with interrupted silk sutures. Then the mouth is thoroughly douched and wiped out, and the child is allowed to recover from ether. When undertaking one of these cleft -palate operations, the surgeon must have abundance of time — two hours, if necessary — and the patience to ])ick his way along, taking each step slowl}-, carefully, and finally. The after-care of these infants and children is important. Blood has been lost, and it is well to assist the circulation by the use of salt solution enemata until the patient reacts well. Careful feeding must be instituted, and the child watched until all danger has passed. The mouth and nares must be wiped out several times a day. The silver stitches should be removed on the eighth day, and the silk stitches two or three days later. If all goes well, healing should be sound in two weeks. The establishment of proper speech habits is difficult in all cases. The developing children should be put under the care of a competent teacher if possible. When these operations are performed on half-grown children or on adults, one may expect an excellent anatomic result, but good speech habits cannot be expected. For years after the operation children should be under the frequent inspection of a dentist and a throat specialist, because all such abnormalities as faulty teeth, nasal spurs, deviated septa, and the like add to the physiologic errors and must be met and corrected. Shocking as is the deformity of a harelip, it is scarcely more re- pulsive than numerous other lesions of the face, congenital and ac- quired, especially the deforming and often grotesque imperfections of the features. The unfortunate victims of such defects are always ob- jects of repulsion on first sight, and the reacting mental effect upon the individuals themselves is often permanent and distressing. Frequently these lesions serve as a grevious handicap in life, though in rare instances one sees such unfortunates attain positions of conspicuous eminence. I have referred to the various unusual clefts and fissures of the cheeks, nose, eyes, and other regions, and the reader will recall a famous case in fiction, Victor Hugo's " I'Homme qui Ris." PLASTIC OPERATIONS ON THE FACE The remedy for these defects nearly alwavs involves a plastic opera- tion, and plastic operations on the face, though anatomically satisfy- ing, since healing is prompt and sound, seldom give pleasing cosmetic results. The patient remains something of a monstrosity, painful to the beholder. Nasal defects especially are deforming, and the remedy, whether by some one of the ingenious plastics or by a false nose, is never satisfactory. These nasal defects appear as a partial or complete loss of substance of the nose. Rarely the condition is congenital; but syph- ilis is a common acquired cause; sometimes the cause is tuberculosis, or PLASTIC OPERATIONS ON THE EACE 545 there may have been an injury. Operations for repair consist in turning down various flaps to fill in the vacancies. Flaps are taken from the forehead, the cheeks, and the side of the nose, as illustrated by the accompanying cuts. The cuts, however, give one little notion of the end-results. The defects may be closed in, the patient rendered more comfortable, and his visage less hideous, but the resulting scars are extensive and extremely ugly. Ectropion, or eversion of the lower eyehd, is not uncommon, and may arise from a burn, ulcer, or injury. There are various operations for its relief, which certainly improve the patient's appearance. Not only this, but they remedy the serious distress which the patient suffers from ectropion, as the everted lower lid continually pours out tears. Fig. 358. — Method of rhinoplasty (Linhart). Defects in the cheeks are remedied by some such operation as that of Schimmelbusch, who reflects upward a flap from the neck. The neck is a favorite region, when suitable, from which to take a flap, for the cervical skin is thin and elastic. In performing all these plastic operations, however, one should take pains not to fill in a normally hairless area, like the forehead or upper portion of the cheek, with a hairy flap. Cheeks and chins extensively scarred by bums are com- monly subjected to these operations. Powder face is a frequent misfortune, and is due to a close-range discharge of black gun-powder, which forces the powder grains into the skin. If the patient is seen at once before the grains have healed in, most of the particles can be removed by vigorous scrubbing with a stiff nail-brush, the patient being under ether. After the grains have healed 35 546 THE FACE AND NECK nur^(.„-^^^^ 4 I %> 'y^ aHH^ Fig. 361. — Carcinoma of neck, secondary to lip cancer (Massachusetts Greneral Hos- pital) . lip, and is a process of slow progress. For this reason, as with other cancers of the face, and because these lesions are on the surface and quickly detected, it seems as though a cure of the growths should be common and easy. Cancer of the lip, however, differs from most other facial skin cancers in this respect, that it involves lymph-nodes much more early than do they. Lip cancer appears at first generally as a scab covering a small, hard, granulating tumor, — perhaps a perithelioma. — no larger often than half a split pea. The patient picks ofT the scab or it falls off, and then gradu- all}' it forms again. This stage may last for two or three years, but even- tually the growth spreads and exfoliates. When once started in this 550 THE facf: axd neck way it may increase rapidl}', and within a few months the whole lower lip is a mass of foul, bleeding, fungus granulations, with an extensive in- durated base. Although this state of progress in lip cancer should never be reached in any civilized conmumity, the condition is seen not uncom- monly. Perhaps unfortunately, the patient suffeis little discomfort from lip cancer until it is well advanced, and he may carry with him for years a threatening nodule without being especially disturbed. In the later stages of the disease great distress comes on, especially pain, debility, pain in the jaw from involvement of the bone, and pain in the neck from metastases. If the disease runs an uninteirupted course, the patient dies in from three to five years, with great swelling of the neck, constant pain, perhaps pressure on the trachea, and obstruction of the Fig. 362. — Extensive epithelioma of lip (Massachusetts General Hospital). esophagus even. Distant metastases are uncommon, for the disease is nearly always limited by the collar of lymphatics above the clavicle. One should observe, moreover, that early lymphatic enlargements are confined to a few nodes in the submaxillary and submental regions; lymphatic swellings lower down in the neck along the edge of the sterno- mastoid appear late, and in this respect cancer of the lip differs from cancer of the tongue, in which latter disease deep lymphatic involvement is relatively early. Probably no class of cancer patients have fallen victims to the malpractice of quacks so frequently as persons suffering from cancer of the lip, yet it should be obvious to every qualified physician that cancer of the lip in its method of growth is analogous to cancer of the breast, CANCER OF THE LIP 551 and demands equally thorough and far-reaching cxtii'pation. I be- lieve that a mere local removal of young lip cancer is always improper — as improper as the mere local removal of a small breast cancer. The treatment of lip cancer must be thorough and early therefore, and when such treatment properly is followed, the surgeon should look for a large percentage of permanent cures. For some years I have fol- lowed the technic advocated by Crile."^ While I believe firmly in ex- tensive dissection of the neck for cancer of the lip, I agree with Crile that such extensive dissection need not be invariable. In operating for early cancer it is enough to remove thoroughly the growth in the lip and to dissect out the tissue — fat, platysma, vessels, and lymphatic and sali- vary glands in the digastric region, corresponding to the side on which Fk 363. — Grant's operation for cancer of lip — step 1. the cancer is placed. The decision regarding more extensive operation sometimes is difficult. A good general rule is to dissect widely the neck only in case one finds that the superficial glands are involved. The problem of the operation for lip cancer, therefore, divides itself naturally into two portions — the operation on the lip and the operation on the neck. The operation on the lip should be done more thoroughly than old convention enjoins. The common method has been to remove the growth by a V-shaped incision and to sew up the cleft. This is poor surgery, except in the case of minute growths, for when a large growth is removed in this manner, and the wide gap is sewed up, there results an ugly, disfigured mouth — the so-called ''sucker mouth." The best incision for removal of the growth itself is the square incision, supplemented by ^ George W. Crile, Jour. Amer. Med. Assoc, December 1, 1906, p. 1780. 552 THE FACE AND NECK such a flap operation as Grant's.' By this operation a wide clean excision of the tumor is made. From the inferior angle of the wound cuts are then carried down obliquely beneath the jaw; the submaxillary region is ex- posed; the suspicious area is di.ssected, and the resulting extensive wound is closed readily by a flap-sliding plastic. A fairly shapely mouth re- sults from the most extensive dissection even, and, if necessary, any lack of mucous border may be supplied from a splitting plastic of the upper lip — Sandelin's cheiloplasty. The more extensive and radical dis.section of the neck (Crile) is an operation of the first magnitude, and in undertaking it one should have regard to three important considerations— infection, hemorrhage, and shock, as well as the primar}- consideration of radical cure. A suitable J0 .^ ^ L^ Fig. 3fi4. — Grant's oporation for cancer of lip — step 2. method of approach is through a T-shaped incision — the horizontal running beneath the jaw from the symphysis to the mastoid; the per- pendicular from the angle of the jaw to the niidtile of the clavicle, cross- ing obIir{uely the sternomastoid muscle. One turns back freely these flaps and proceeds, as in the removal of breast cancer, to take out the whole of the infected area, including in the dissection fascia, fat, sali- vary and part of the parotid glands, sternomastoid, omohyoid, and part of the stylohyoid muscles, the entire venous system, and all the lymphatic vessels and glands in this region. This comprehensive dissection is quite as extensive and complete as the thorough dissection for breast cancer. One begins the deep dissection from below, cutting away the sterno- mastoid close to the clavicle, reflecting it upward, tying the deep and su- - W. W. Grant, Jour. Amer. Med. Assoc, September 30, 1905, p. 962. CANCER OF THE LIP 553 juM-ficial ju.uulars, and conti-()lliii<;- possible hcniorrha^c b}' the temporary i-laiups of Crile plucecl u]Jon the common carotid. With this as a bciiin- Fig. 365. — Grant's operation for cancer of lip — step 3. Fig. 366. — Grant's operation for cancer of lip — step 4. ning, all the parts I have named may be freely and rapidly removed, peeling from below upward, avoiding possible infection by handling the mass as little as possible, minimizing hemorrhage by controlling quickly 554 THE P'ACE AND NECK all severed vessels, and obviating shock b}- the application of the pneu- matic suit. As 1 have insisted previously in discussing the removal of cancer, we must not be goverend by considerations of anatomy. The loss of the sternomastoid and other muscles is quickly compensated ; the loss of a large part of the venous system is of no moment whatever, for numerous veins, deep and superficial, quickly enlarge to supply the lack; control of the carotid is temporary only, and in a large experience 1 have seen no damage follow the use of Crile's clamp carefully applied to that vessel without forcible compression. This neck dissection is a some- what formidable oi)eration, and may result disastrously if any of the suggested precautions arc neglected. Moreover, one should take e\-ery pains to avoid damaging the pneumogastric nerve with its connections. On completing the dissection one sees a broad, clean, deep wound, at the bottom of which lie arteries and nerves only upon the deep cervical muscles. Sew up the wound carefully, and leave a cigaret drain at its lowest angle. Rapid healing is promoted by supporting firmly the neck for a w^eek in a Thomas collar or some similar device. Let me say to the practitioner that I am aware some surgeons doubt the wisdom of this wide operation, but abundant experience of my own and the still wider experience of Crile and others have convinced me that nothing short of this gives reliable promise of permanent cure in grave cases of extensive cancer of the lip and neck. It seems almost needless to say that involvement of both sides of the neck with massive tumors, that profound cachexia, and the suspicion of distant metastases contraindicate positively any operation whatever. Another form of cancer of the face is that curious and unique process which we call rodent ulcer. RODENT ULCER This is a cancer originating in the sebaceous glands. The disease may arise anywhere on the face — especially on the nose, eyelids, and Fio;. .367. — Rodent ulcer. cheeks. Its first manifestation is a little knob about the size of a split pea, harmless and little noticed. The knob may remain for years, when INJURIES OF THE FACE 555 suddenly, without obvious reason, it begins to ulcerate and to progress, destroying all the superficial parts in its neighborhood — skin, muscles, fat, cartilage, eyeball, and bone — producing a horrible disfigurement. It grows unceasingly; it is painless; it gives rise to no metastases; it appears as a raw, sloughing, indolent ulcer. Its origin is in the sebaceous glands, as I have said, and the little original nodule is seen microscopically to consist of gland-ducts filled with epithelium. For years surgeons treated rodent ulcer by the cautery and by ex- cision, followed b}^ extensive plastic operations. Of late we have come to believe that when exposed to radium, the disease is aborted rapidly, and the ulcer heals without leaving a scar} There are sundry other injuries and diseases of the face, at a few of which it may pay us to glance. INJURIES OF THE FACE Injuries of the face, when promptly treated, heal rapidly, for the tissues of the face are remarkably vascular and primary union there occurs in a few hours. Infected wounds even are subdued more readily, as a iTile, than are similar wounds elsewhere. One of the commonest types of infection of the face is — Facial Erysipelas. — This is due to streptococci, which find lodgment in some crack or trifling abrasion. It is a surgical affection.- The result- ing inflammation spreads rapidlj' — commonly about the eyes as a center. It presents the appearance of a uniform scarlet blush or injection of the skin, with a sharply marked outline. Generally, the disease runs a short course, and in a few days disappears spontaneously; but if unchecked, it may progress indefinitely over the body; the infection may burrow, and there may result extreme deep inflammations with pus — a condition known in former times as " phlegmonous erysipelas." An excellent treatryient in the "early stages of the infection consists in the frequent application of a lotion composed of alcohol and carbolic acid.^ In spite of the feebleness of this antiseptic it generally succeeds in quelling the disturbance in a few hours or days. Another popular treatment consists in painting the edges of the advancing inflammation with ichthyol. When the infection has progressed far and has involved deeper structures, it must be treated vigorously by incisions and anti- septic dressings. I am coming to believe that opsonic vaccines will mitigate or abort this infection, but at present the evidence is not con- clusive. Carbuncle of the upper lip deserves a word of mention here, in addition to the consideration of carbuncle in general, which the reader will find in Chapter XXVI. Carbuncle of the upper hp is peculiarly serious. It is situated in an extremely vascular region, and often goes unrecognized for many days — especially in the case of a bearded lip; 1 Tumors, Innocent and Malignant, J. Bland-Sutton, 1907, fourth ed., p. 325. 2 A rather convenient cant term, which implies that the treatment of the case should be in the hands of a surgeon, as an operation may prove necessary. 3 I^. Acid, carbolic, 4.00; spirit, vini recti., 30.00; aquae, ad 200.00. 556 THE FACE AND NECK often it is progressive and fatal even, involving eventually deep stnic- tures of the face and neck and spreading perhaps to the meninges. The surgeon should treat it vigorously at the outset, by excising the nidus of infection, if such excision does not mean extensive crippling of the face, or by deep crucial incisions and cureting. At the same time he should employ opsonic vaccines. If the inflannnation has extended far, the. siu'geon must meet the indications by appropriate far-reaching incisions for drainage. TUMORS OF THE FACE Angioma, a tumor composed of an abnormal formation of blood- vessels, is common on the face, and is seen in three forms: (1) Simple nevus; (2) cavernous nevus; (3) cirsoid aneurysm. The simple nevus is far the most common, and is ordinarily designated " birth-mark." It may be small and superficial or it may be so extensive as to cover the side of the face — the so-called '' port-wine stain." Nevi are composed of minute blood-vessels embedded in fat and communicating with an Fig. 368. — Nevus (Massachusetts General Hospital). adjacent artery or vein. Cavernous nevi, sometimes called erectile tumors, are made up of spaces and sinuses, the walls of which are merely fibrous septa lined with epithelium. Sometimes the cavernous nevi consist in part of vessels and in part of cavernous spaces. Like simple nevi, they are general!}^ congenital, but, unlike simple nevi, they grow. They may burst and bleed; they may press upon such organs as the tongue and nares, and then rupture, endangering life even. These two forms of nevus may be treated by excision if they be not too TUMORS OF THE FACE 557 extensive, or, in the case of caveinous nevi, by the injection of boiUng water into the mass. The latter method is simple. Boiling water is forced through a common hypodermic needle, inserted in several places into and beneath the nevus, until all parts of the tumor have been reached. There results coagulation and necrosis, with subsequent absor])tion and more or less fibrous tissue formation, but ultimately with pleasing cosmetic results. More than one sitting may be required, and many months may pass before the swelling disappears entirely.' Cirsoid aneurysm consists of numerous arteries arranged in a tor- tuous fashion. These angiomata are rare, disfiguring, troublesome, or Fig. 369.- — Treatment of nevus by boiling water. in the end dangerous, and can be treated by careful excision only. When the whole mass becomes so extensive as to involve half the forehead or more even, its cure is extremely diflficult, and requires numerous successive operations, with careful painstaking dissection. So much for the lesions of the face which concern the surgeon especi- ally. There are in this region numerous other disorders involving the skin and special organs, but for the study and treatment of these dis- orders I must refer the reader to appropriate special treatises. ^ Recently surgeons have successfully removed nevi by applications of liquid air or carbon-dioxid snow. CHAPTER XXI JAWS, TONGUE, LARYNX, AND PHARYNX The Jaws The surgery of the tongue and jaws is associated closely with the surgery of the face, — the subject of the preceding chapter, — as well as with the surgery of the neck. The lesions of these parts are of supreme importance not only to life and health, but to comeliness and beauty, so that, in a large sense, they should fall to specialists. Indeed, certain portions of the problem have been divided among certain specialists — laryngologists and dentists — upon whose field I intend to trespass but little. There are, however, many associated lesions which fall as yet to general surgeons. There are fractures, deformities, malignant tumors, and infections in great variety, at most of which we must glance. A special study of all these lesions is impossible in our limited pages, but I shall take occasion to refer the reader to sundry important essays and monographs. Fractures and dislocations of the jaws will be considered under a special chapter of this book, on the general subject of fractures (Chapter XXIX). The buccal cavity is peculiarly liable to infections, because the mouth is a swarming breeding-place of micro-organisms, which may find ready lodgment about the teeth and gums or in cracks of the tongue and lips, and so produce infections. Moreover, the mouth is a cloaca concerned with both the respiratory and the digestive tracts, so that infections and lesions of the mouth, fauces, stomach, and air-passages may be related and interdependent. The mouth, jaws, and tong-ue are peculiarly liable to injuries and irritations; the head and face are at all times exposed to the weather and to violence, while the tongue and cheeks, lying in contact with the teeth, may suffer from such contact, especially if the teeth be broken, jagged, and decaj'ed. The development of the teeth themselves, their relation to health, to their own function in digestion, and to anatomic obstructions by tumors and deformities in the mouth, fauces, and nasal passages, all go to make up an independent and important chapter in surgery. As I said in speaking of face lesions, the surgery of all these parts differs from most other surgery in that it has in it a peculiar factor — the factor of possible cosmetic deformity. Aside from this factor, which one must constantly be considering, one must regard possible involvements of the special senses. There are, however, three main types of lesions which we must study in this chapter — infections, injuries (and their results), and tumors. 558 INFECTIONS 559 INFECTIONS Alveolar abscess (" gum-boil") is a common and distressing affec- tion. It appears as a painful, throbbing swelling of the gum, quickly followed by an associated swelling of the cheek, which assumes an ap- pearance of ludicrous deformity within a few hours. The infection starts in or about the root of a tooth, quickly involves the periosteum, and spreads to the mucosa. If you examine it with your finger, you find a sensitive area on the gum over the affected tooth, with swelling of the gum extending to the cheek. Within a day or two you find the swelling to be fluctuant. If left untreated, this little abscess will open and discharge, but after a number of days only. In its early hours the inflammation may sometimes be aborted by the frequent use of hot myrrh mouth-washes and small internal poultices, worn within the mouth. Large external poultices are comforting, but one should not depend upon them too long, as they may encourage the burrowing of pus and its opening through the cheek, especially when the abscess springs from the lower jaw. In all cases, however, the surgeon should cocainize and open the g-um-boil as soon as it shows signs of fluctuation. The relief is instantaneous and the cure prompt. Later, the patient should consult his dentist for repair of _ the tooth which has set up the trouble. Sometimes these infections progress deeply and result in osteomyelitis of the jaw" bones. Osteomyelitis may be due to other causes — to some general systemic infection, to some localized infection of the mouth, or to phosphorus- poisoning. The progress of such bone infections is rapid and extremely painful. Their seat commonly is in the lower jaw, because the mandible only has a medullary cavity. Destruction of considerable areas of bone or of the whole jaM' even may result, wdth extensive suppuration, se- questrum formation, and dropping out of the teeth. Active surgical treatment is imperative — early free incision, opening of the medullary cavity, and competent drainage. If such prompt treatment has been neglected, the surgeon finds himself consulted by the patient in an ad- vanced stage of chronic bone disease, with burrowing sinuses, at the bottom of which lie bare bone and necrotic sequestra. Such a condition necessitates a tedious form of treatment — laying open the sinuses, ex- posing the bone, removing the sequestra, and looking for a slow repair, should a proper amount of periosteum and endosteum be left for repair. A cure in such fashion cannot always be expected, however, and exten- sive destruction of the jaw^, wdth serious crippling and deformity, may result. This unfortunate condition will tax to the utmost the resources of the surgeon, and will lead him to attempt some form of plastic re- construction.^ There are other and more insidious forms of infections of the jaw bones. The so-called necrotic caries is a familiar example of chronic disease of the jaws — a disease which attacks by preference the superior ^ Carl Beck, Plastic Reconstruction of the Lower Jaw, Jour. Amer. Med. Assoc, April 21, 1906. 5(30 THE FACE AND NECK maxillary bone at the infia-oibital rid^e and the malar bone. It is usually of tuberculous origin, and must be treated by vigorous cureting, the removal of all obviously necrotic tissue, and the enjoining of an out- of-doors life. There results, after the healing, an ugly facial scar, often causing ectropion of the lid, which must be corrected by a subsequent operation. One of the commonest and most obstinate infections of tlie upper jaw is that which involves the antrum of Highmore and leads to em- l)3'ema of the antrum. This infection ma}- originate either in the teeth or in the nasal bones. It belongs properly to the throat specialist, and I refer the reader to special monographs and larger works on this subject. Besides these immediate and active results of acute infections of the jaws the surgeon must deal with their after-results, most conspicuous among which is lock-jaw. Mechanical lock-jaw originating in tlisease of the mandible is rare, but lock-jaw resulting from disease of the soft parts of the mouth and face, which cause contractions, is much more common. The latter form of lock-jaw is that which we see frequentl}'' in out-patient clinics, and its treatment taxes severely the surgeon's patience and ingenuity.^ The contractures are due directly to solid, cord-like bands of tissue, following destructive ulcerative changes (noma) which have their origin, as a rule, in the buccal mucosa. The rare arthritic bony fusion must be treated by partial excision of the joint, but the treatment of the cicatricial contractures is another matter. These contractures, which occur most often in young children, ai'c a grave menace to health; the jaw becomes set; mastication is impossible; the patient must live on liquid nourishment ; the teeth become dwarfed, deformed, and diseased; the mandible itself fails of development, so that the facial expression and outline become distorted, and the patient suffers grievously in both mind and body. If these contractures be seen early and are unilateral, vigorous mechanical treatment may suffice for a cure. Implements are used for the purpose of forcing apart the jaws and enabling the patient to pursue a course of ruminant gymnastics. A great variety of apparatus has been divised for this purpose — wooden thumb-screws and wedges are the most familiar, but their use involves the serious disadvantage that they may break or otherwise damage the teeth. ]\Ioreover, their employment is extremely painful. Curtis ^ has employed a double screw-plate which is serviceable. By such means it frequently happens that a satisfactory jaw is secured. On the other hand, old neglected cases cannot be so treated. These are the cases in which the lesions are cicatricial and bilateral, and have persisted so long and are so deeply placed that degenerative and developmental changes in the mandible and its condyle have taken place. Sometimes one may gain a certain amount of motion by dividing the cicatricial bands and employing mechanical massage, but for the more serious cases ^ Rudolph Matas, Operative Treatment of Bilateral Cicatricial Ankylosis of the Jaws, Jour. Amer. Med. Assoc, November 28, 1903. - G. Lenox Curtis, Ankylosis of the Jaws, ibid., July 2, 1904. TU.MOR.S OF THE JAWS )61 some form of extensive plastic operation is required — splitting the cheek and turning into the buccal cavity skin-flaps from the face or neck. A number of ingenious procedures of this kind have been devised, for a stud}- of which 1 refer the reader to flatus's valuable paper. ^ TUMORS OF THE JAWS Tumors of the jaws are common also, especially benign tumors, because the maxillary bones, on account of their peculiar formation, the fact of dentition, the presence of the antmm, and irritations arising in the buccal cavity arc especially disposed to tumor formations. There is the subperiosteal cyst of the alveolar process, which orig- inates in a subperiosteal abscess, with the separation of the periosteum and the subsequent formation of a new bony laj-er which ma}' cause the formation of a considerable swelling, either crepitant or solid to the touch. Such a cyst sometimes is cured by drainage through the extraction of carious teeth; sometimes it is necessary to incise and curet the cvst. Fig. 370. — The second right mandibular molar of a Chinaman, aged nineteen years, with a swelling possessing the characters of a composite odontoma: A and B, Tooth, natural size; C, enlarged and in section (Keen's Surgeiy). Fibromata of the jaws are not very common, but one finds them occasionally on the alveolar process about the canine teeth. Carefid re- section of the alveolar process is necessary for their cure. Odontomata and dental cysts are the most troublesome and fre- quent tumors of the jaw. They spring from dental tissue at different stages of its development, from teeth germs or teeth still in the process of growth. Bland-Sutton ^ has given us an extremely interesting chapter on this subject in the last edition of his valuable book. It is needless to discuss the seven varieties of odontomata. Suffice it to say that these peculiar growths consist of structures of varying histologic type and arrangement, and that they produce bone-like swell- ings of considerable size, which contain spaces in which are found frag- ments of teeth or whole teeth unerupted and embedded. Odontomata may occur in either the upper or the lower jaM-, and the follicular species 1 Rudolph Matas, ibid. , 2 J. Bland-Sutton, Tumors, Innocent and Malignant, fourth ed., 1907, p. 227. 36 562 THE FACE AND NECK is often multiple. That form known as the composite species may in- vade the antrum and attain the size of an infant's fist. An important point in their clinical history is that in nearly all these cases the tumor remains quiescent for a period, and that then there comes a time in which, like the teeth, it seems to erupt, making its way above the gum, and causing often profound constitutional disturbances of a septic character. This phenomenon of eruption occurs usually between the twentieth and twenty-fifth years. The diagnosis of these tumors has been a matter of great difficulty in the past, and the growths have been regarded often as malignant neoplasms. Fortunately, to-day the x-rays serve to clear up obscure diagnoses by showing cysts and unempted teeth. Odontomata have been objects of a deal of bad surgery in the past, and com- petent operators, influenced by mistakes in diagnosis, have removed large jjor- tions of the jaw. No such disabling operations are necessary. In the case of a questionable tumor of the jaw, es- pecially in a young person, the surgeon should ascertain its peculiar character by the a:-rays or by microscopic study, if necessary. An odontoma requires merely enucleation of the growth, while one peculiar form onh", the follicular odon- toma, demands complete removal of the sac. Dental cysts are growths connected with the roots of teeth, from which they hang ofl" as a cherry hangs from its stem. These cysts are fibrous bags filled with a mucoid fluid. They vary from the size of an apple seed to that of an English walnut, and frequently are connected with the dead roots of molars in either the upper or lower jaw. These cysts do not contain teeth, as do the tme odontomata. with which one should not confound them. The c}'st must be attacked by drawing the teeth involved, enucleating thoroughly the sac, and packing the cavity with sterilized gauze. While the odontomata are the most interesting of benign tumors of the jaws, there are sundry other tumors which are more YHYQ—osteomata, bony outgrowths which offend merely by their size and pressure upon special structures— nerves, the eye, the nasal cavities, and the mouth: adenomata and chondromata also; but they are quite uncommon as com- pared with malignant tumors. Malignant Tumors. — Of these, sarcoma is somewhat more com- mon than cancer, and the commonest form of sarcoma of the jaws is of that giant-cell type known to surgeons as epulis. Epulis is one of the least malignant forms of sarcoma. It arises from the periosteum of the alveolar process, grows slowly, and tends to envelop the bone. It appears at the edge of the teeth as a curious pig- Fig. 371. — A follicular odon- toma from the right half of the mandible of a boy aged fourteen years (Bland-Sutton in Keen's Surgery). TUMORS OF THE JAWS 563 merited excrescence, and is the only form of pigmented sarcoma that is not exceedingly malignant. If untreated, it spreads gradually so as to involve largo portions of the jaw, and causes falling of the teeth until eventually, and after many years, it kills the patient through encroach- ment upon, and destruction of, important organs. It is not difficult to .eradicate epulis early, but half-measures do not avail. The surgeon must draw the teeth in the neighborhood of the growth and excise thoroughly the tumor with the adjacent gum and a portion of the jaw, cutting freely about the disease by a margin of one-half inch at least. This operation, though strictly local and not especially deforming, cures the patient permanently in most cases. If the growth recurs, it Fig. 372.— Epulis. recurs locally and can be removed surely by the merest local treatment — by excision, the cautery, or the curet even. Sarcoma of the body of the jaw is a far more serious matter than epulis. Epulis is a disease of young adult life, sarcoma of the body of the jaw is a disease of middle age. This latter form of tumor is a round- cell sarcoma with a scanty stroma. It appears in both the upper and the lower jaws and extends rapidly until it involves all the bones of the face, as well as the neighboring soft parts. It recurs commonly after being removed, and the only treatment which holds out any promise of cure is extensive and deforming resection of all the parts involved. The upper jaw sometimes is the seat of a periosteal sarcoma arising 564 THE FACE AXD NEf'K from the gums, though the conmion situation of periosteal sarcoma is in the antrum, where it causes great enlargement of the bone and en- croaches ui>on the nasal passages, the orbit, and the sphenomaxillary, zygomatic, and temporal fossa*. This is a tumor of rapid growth. It occurs commonly in young adults, and nuiy kill the victim within a year. Lymphatic involvements and distant metastases rai'ely are associated with these sarcomata of the jaws. Cancer involves the jaws but secondarih-, wheieas sarcoma there is primary. Cancer spreads from the soft parts to the neighboring bones of the jaw. Seldom does it appear before middle life. Since cancer attacks the bones from without and through the mouth, it is almost ahvays associated with infections and foul ulceration. The victim of cancer about the jaws is an object loathsome to himself and to those about him. Young cancer of the jaw ma}' simulate epulis, and for this reason a carefid microscopic study invariably should be made of growths about the base of the teeth. In distinguishing clinically between epulis and cancer, observe that cancer ulcerates, while epulis rareh' does so; and that cancer produces enlargement of the lymph-nodes, which is not true of epulis. Extensive cancer may involve the bony fossa^ within and behind the upper jaw, but such cancer rarel}' is primary there. Whether primary or not, the surgeon must distinguish it from the rountl- cell sarcomata which are the common growths of that region. Cancer of the jaws progresses rapidl}' when once it has become established, and may destroy the patient within a year. It invades the orbit, the nasojoharynx, the submaxillary region, and involves exten- sively the lymph-nodes of the neck, often attacking the skin, and appearing externally as an ulcerated, sloughing mass. One sees, there- fore, that cancer in the deep parts of the face calls for early and thorough treatment. Treatment must be by the most radical excision if it shall avail. Various forms of treatment other than excision have been advocated from time to time; but although the x-rays and radium have seemed to promise something, we cannot yet avoid the conviction that our only, though feeble, hope of cure rests in the knife. It is a disap- pointing fact that operations for cancer within and about the mouth and jaw's seldom cure. So true is this that surgeons look upon a patient who is well three years or more after a radical excision of cancer about the mouth (except cancer of the lip) as a curiosity. Let us consider briefly the operations of — Resections of the Upper and Lower Jaws. — These operations, with their various modifications and extensions, form the feeble staff on which we must lean when dealing with malignant disease of this region. The upper jnir may be removed with a resulting deformity sur- prisingly slight when one considers the extent and severity of the opera- tion. I apply a clamp to the carotid as a preliminary step. Then, following the method of Ferguson, one turns back a skin-flap through an M-shaped incision traced along the inferior rim of the orbit, the base of the nose, about the ala, and down through the upper lip. I prefer to TUMORS OF THE JAWS 565 operate with the patient in the upright position, as he can thus be tipped forward readily for the expulsion and clearing out of blood and mucus from the mouth. However, there should be no considerable hemorrhage. Ether anesthesia with the ordinary cone is satisfactory. The surgeon enters the knife at the base of the zygoma, carries it at once down to the bone and completes the deep incision with a series of firm sweeps. Then he turns back quickly the soft parts of the cheek from the upper jaw, exposing completely, thoroughly, and easily all those bony sti-uc- tures which are to be removed. He then controls the hemorrhage in the flap and proceeds to the excision of the maxilla itself — an under- taking less difficult than would appear at first sight. A short, powerful saw. a stout knife, and a pair of heavy grasping bone-forceps are the im- Fig. 373. — Lines of incision for resection of the upper jaw (Fowler). portant instruments required. Detach from the bone the nasal cartil- ages at the edge of the incision. Divide then with the saw the nasal process of the superior maxilla, from the junction of the nasal process with the lower border of the nasal bone, and carry the cut to the margin of the orbit just below the canal of the nasal duct. Then follows the important step of preserving the eye; to this end raise the periosteum from the floor of the orbit (together with the origin of the internal ob- lique muscle) and retract upward these soft parts. Chisel obliquely across the orbital plate from the end of the saw-cut to the anterior end of the sphenomaxillary fissure. This clears the orbital and external surfaces of the malar bone. Complete the division of the malar bone, using the straight short saw or the Gigli passed through the spheno- 566 THE FACE AND NECK maxillary fissure and zygomatic fossa. It remains to extract the now loosened maxilla. To effect this, divide the mucoperiosteal covering of the hard palate in the median line, as well as the mucoperiosteal covering of the floor of the nose, cutting as near the septum as possible. Then make a transverse cut across the roof of the mouth at the junction of the hard and soft palates, and with a saw divide the horizontal plate and the palatal and alveolar portions of the upper jaw. Now grasp with a large bone forceps the seijarated jaw bone and break it away from its few remaining attachments. It separates easily, and one may catch with forceps successively the bleeding points which are thus brought into view. The upper jaw being removed, a vast gajnng cloaca is re- Fig. 374. — Resection of half of the upper jaw. Dissection of the flaj) from the bone (Fowler). vealed, which I, as a young medical student, remember gazing upon with fascinated horror. The healing of these extensive wounds generally is prom])t and un- complicated. The patient suffers surprisingly little discomfort, except from the sense of loss of substance. At the primary dressing of the wound there is need for considerable packing of the raw cavity, but granulations quickly spring up, and the packing must be removed and renewed almost daily after the third day. By the end of two weeks a fair degree of healing is established, so that no further dressings are necessary beyond the frequent irrigation of the mouth and pharynx, which must be continued so long as discharges persist. It is not dif- ficult to feed these patients. They may be nourished through a nasal TUMORS OF THP] JAWS 567 Fig. 375.- — Lion-jaw forceps grasping the resected portion of the upper jaw (Fowler) Fig. 376. — External Incision for resection of half of lower jaw (Fowler), feeding-tube for a few days, but they learn to swallow naturally in a short time. 568 THE FACE AND NECK I have said that the outlook in these cases is not encouraging. Occasionally sarcomata when removed do not return, but when the operation is done for cancel-, that treatment must always be regarded as a palliation. Excision of the lower jaw usually means excision of half of that bone. Removal of the whole bone is done rarely. The technic of removal of half of the lower jaw is as follows: Control hemorrhage by a temporary clamp on the carotid; beginning at the chin make a vertical cut from just below the border of the lip down to the jaw bone, and carry the cut around the angle of the chin; from this point, with the knife close to the bone, carry the incision along the mandible up to and beyond its angle nearly to the ear, stopping short of the facial nerve; take up the ''^. '•n^ Fig. .377. — Temporary clamp (Crile's) on carotid. facial artery as the knife passes it; then lift the periosteum from the ex- ternal surface of the bone, from the symphysis outward; control hemor- rhage; cut away the buccal mucosa from the line of the teeth; extract one of the incisor teeth, and saw through the symphysis ; seize the loos- ened bone with heavy forceps, draw it outward and divide the various muscular attachments — the mylohyoid muscle, the internal pterygoid; the temporal and the external pterygoid; open the capsule of the joint; cut away the ligaments and remove the bone. Then control all bleeding points and sew up carefully the resulting wound. Take pains especially to make a close joint of the severed mucosa, for the mucous membranes heal readily when properly approximated. As I have stated, in doing this operation and other extensive dis- THE TONGUE 569 sections about the nock and face I am accustomed to follow Crile's suggestion of clamping previously and temporarily the common or external carotid artery, using for that purpose Crile's well-known artery clamp. I have been impressed also by the value of Crile's shock-suit, which I employ commonly when doing extensive operations about the neck and head, the patient being placed in a modified Fowler's position, at an angle of about 45 degress. In the case of old and feeble persons with advanced cardiovascular disease these extensive excisions are dangerous and the mortality high, the patients sometimes dying within a few hours or lingering on for a week. In the case of such patients, therefore, the surgeon should approach the operations with the greatest hesitation. Younger and more vigorous persons, however, rally promptly, and often live to enjoy a fairly comfortable existence, though the deformity, especially in the case of women, is considerable. Excision of the entire lower jaw sometimes must be undertaken in cases of phosphorus necrosis, which causes an almost total destruction of the bone. The operation is a mere extension and duplication of that I have described already ; or sometimes the bone may be removed from within the mouth. In any case the periosteum should be preserved so far as possible. Rarely a complete removal of the jaw is necessary. The Tongue The tongue is probably the most important organ, after the eye, concerned with the special senses. Inasmuch as its functions have to do with speech, taste, and deglutition, any ailment or lesion of the tongue becomes instantly of prime importance to the patient. The tongue, like the heart, is an organ of simple stiiicture, made up almost entirely of muscles. It springs from the hyoid bone, is attached to the lower jaw, and is a much larger structure in extent than casual inspection would in- dicate. When the physician '' looks at the tongue " as part of his routine inspection, he sees little more than its tip and the anterior quarter of its dorsum. Two sets of muscles compose the tongue — such extrinsic muscles as the hyoglossus and styloglossus, which pull the tongue back, and the genioglossus, which pulls the tongiie f onvard ; but the main im- portant muscle is the lingualis, which arises from the hyoid and makes up the greater part of the tongue's bulk. The hypoglossal and chorda tympani nerves supply the tongue with innervation, while the most of its blood reaches it through the ling-ual artery, which springs from the external carotid. The circum vallate papillae lie close to the larynx, in the root of the tongue, and numerous mucous glands cover the dorsum of the organ. The mucosa of the dorsum is thick and rough, but the mucosa beneath the tip of the tongue is extremely thin and cleKcate. The tongue throughout is intersected by large and frequent lymph radicles. It is a flexible, active, sensitive member, but, fortunately for the human race, it readity resists pathologic damage, so that in spite of its unique structure and exposed position, it is not often diseased. The surgeon is interested especially in two types of tongue lesions — \ 570 THE FACE AND NECK inflammations and tumors. There are other abnormalities of the tonjrue which occasionally one sees — defoiinities, the most important of which is macroglossia — a ssed and, as a rule, the tracheotomy tube should be removed permanently as early Fig. 384. — Intubating the laiynx (Lejars). as possible. The care of one of these patients after tracheotomy is a somewhat delicate and important matter. During the first hours a nurse Fig. 385. — Intubating the larynx (Lejars). should attend constantly to the tube, seeing that it is not plugged and that the patient breathes comfortably, attending to the condition of the sponge, and keeping the temperature of the room at about 80° F, It DISEASES OF THE LARYNX 583 is an unfortunate fact that these wounds frequently become infected, either from the skin or the tracheal mucosa. Special care in cleanliness is, therefore, required lest the patient contract an inhalation pneumonia. In certain cases a more radical opening of the trachea than that I have described becomes necessary — an opening which shall cut off per- manently and entirely the trachea from the upper air-passages. To this end the trachea is amputated completely at the selected point, the stump drawn forward, and its whole circumference stitched carefully to the skin. In this case, if a flattening of the trachea does not result, a tracheotomy tube is needless, for air should pass freely into the open trachea. After these preliminarj- considerations let us now turn to the difficult subject of — Tumors of the Larynx. — For the general surgeon malignant disease of the larynx, necessitating removal of that organ, is the onlj' tumor of in- terest. Other neoplasms there are — papillomas and fibromas and others — which the lar}Tigologist removes by an internal operation. Sarcoma of the lar}-nx is rare, and when it does occur, springs from the lateral wall, but — Cancer of the larynx is the most im- portant malignant growth found in this organ. It may be primary or secondary. When secondary, it is an extension of the disease from the tong-ue, jaws, or gullet, and its removal under these circumstances is impossible or futile. Primary cancer of the larynx must engage our present attention. Primary cancer is divided by Krishaber into two classes — the intmisic form, beginning in the vocal cords, the ventricular bands, or the parts below; and the extrinsic form, starting in the epiglottis, the arytenoids, or other parts outside of the larynx proper; and this classification is now commonly accepted by surgeons. Intrinsic cancer is papillomatous in character, warty in appearance, slow in growth, and associated rarely with lymphatic involvements. The extrinsic form, on the other hand, grows rapidly and early extends through the lymphatic channels. The reader ■wiU see at once, therefore, that the two forms present quite distinct prob- lems. The intrinsic cancer, if taken early, maj^ be removed with good hope of a permanent cure. The extrinsic cancer is a rapidly fatal dis- ease, for which operation is a desperate remedy at the best. Fortunately, the location of lar3'ngeal cancer brings the disease early to the attention of the patient and drives him to consult a physician. The sufferer perceives increasing hoarseness leading to aphonia, with pain as a late symptom. The surgeon, by the aid of the laryngoscope, discovers a tumor or ulceration, and should remove a bit of it to confirm the diag- nosis of cancer, if possible, for that disease not infrequently has been mistaken for benign papilloma or for tuberculosis. If the case mns on Fig. 386.— Cohen's tracheot- omy tubes: 1, Outside tube and obturator; 2, obturator; 3, inside tube; a, cross-section of the tube (Fowler). 584 THE FACE AND NECK without operation, death takes phice in one of two ways — by suffocation or by exhaustion through metastasis. The reader may remember that the latter event befell the late Emperor Frederick, of Germany, whose more urgent symptoms were relieved by a timely tracheotomy. Patients often are loath to submit to removal of the larynx, in which removal lies the only possible hope of cure, so that it is not uncommon to see these victims die after a miserable existence, prolonged by a palliative trach- eotomy, which they always welcome gladh'. Various operdtions for the cure of kuyngeal cancer are advocated by various authorities. There is intralaryngeal removal; remo\-al by splitting the cartilages from without; Kocher's subhyoid pharyngotomy; excision of one-half the larynx, and total extirpation of the larynx, as first performed by Watson and Czerny, and improved by Keen, Gliick, and others. I leave the discussion of the first three methods to other pens. I am not convinced of their efficiency, for neither a -priori nor by statistics do they appear to be curative. Cancer of the larj-nx, like cancer elsewhere, calls for radical and sweeping excision. Most cases, therefore, should be treated by the total extirpation, a description of which may be modified to cover partial extirpation. Siuichy methods of total extirpation are described, but I am convinced that ^^^ AV. Keen's method promises the best satisfaction. I must anticipate the descrip- tion of Keen's method by reminding the reader that the great danger of operations upon the larynx and trachea lies in the possibility of sub- sequent sepsis and an inhalation pneumonia. The mortality from pneumonia is high. The operation of laryngectomy is not very difficult, and is not attended with great shock, so that the immediate after-con- dition of the patient seems excellent, but the diffuse bronchitis and pneumonia, which supervene so often, lend terror to an operation other- wise satisfactory. All operators, therefore, have endeavored to devise some means of cutting off the lower air-passages from the possibility of a contamination extending downward from the larj-ngeal wound. The steps of Keen's method are somewhat as follows: For a week jirior to the operation the patient's mouth and fauces should be thoroughly brushed and gargled frequently, in order to clear up any possibly lurking source of infection. The operation is performed with the patient's neck extended over a pillow or in Rose's position, so as to make prominent the larynx and trachea. Expose the windpipe from a])ove the hyoid bone to the third tracheal ring. Separate thoroughly, b}' blunt dis- section, the structures to be removed, and check all bleeding. Then put the patient in the Trendelenburg position, divide transversely the trachea well below the disease, and attach the lower tracheal stump to the skin, either in the original skin incision or in a special skin button- hole, and intubate the trachea, continuing the anesthetic through a nib- ber tube led out of the tracheotomy tube. The rest of the operation may be done safely and at leisure. Seize the upper tracheal stump and draw it forward with the attached larynx. Carefully separate the parts from the underlying esophag-us, and if the esophagus be wounded, close it at once with stitches. Remove entirely the diseased larynx. Draw down DISEASES OF THE LARYNX 585 the epiglottis, remove it, and complete the operation by suturing the anterior wall of the esophagus to the tissues just below the hyoid bone, so as to prevent leakage from the mouth into the wound. Then remove the tracheotomy cannula and close the external wound, providing drain- age for twenty-four hours. The dressings of the laryngeal wound and of the tracheotomy opening must be kept separate, and Binnie suggests strapping a small frame, like a pillow-box, over the tracheotomy open- ing, so as to protect it and supply a base for a gauze air-filter. The time of after-treatment is an anxious time. The patient should be in bed without a pillow, the foot of the bed being slightly raised, and for two days he should be fed by nutrient enemata. After that he should be gotten out of bed daily, and should be encouraged to swallow, or to take nourishment through a stomach-tube, the nurse meanwhile attend- ing constantly and carefully to cleanliness of the wound. If all goes well, the patient should be beyond danger by the end of the week. Partial extirpation of the larynx is performed in much the same fashion, one half of the larynx, split from before backward, being re- moved. An encouraging number of cures have been reported as a result of this operation, and the final condition of the patients is not so grievous as one might suppose. In some fashion they acquire an ability to talk, or to whisper at least, and the function of swallowing is completely restored. CHAPTER XXII THE NECK Most American surgeons, when they deal with the surgery of the neck, will think of the brilliant recent work of Crile and of C. H. Mayo. Crile's advocacy of extensive block dissections, temporary occlusion of the carotids, and the use of the pneumatic suit to combat shock, constitutes an important advance in the surgery of this region; while Mayo's con- tributions to the treatment of goiter — especially exophthalmic goiter — are notable. We have already discussed many problems of neck surgery — incidentally, when we were considering malignant disease of the mouth and diseases of the upper air-passages. Certain important groups of glandular swellings and diseases of other cervical structures will occur to surgeons as presenting other important problems. In this chapter we shall consider deformities of the neck due to cicatrices, injuries, and neurosis; tuberculous adenitis; cervical abscess; tumors of the carotid body; enlargements of the lymph-nodes; abnormal cervical ribs, and thyroid tumors. CICATRICIAL CONTRACTIONS Cicatricial contractions due to extensive superficial burns of the neck produce some of the most distressing deformities with which we have to deal. The skin over the front of the neck is thin, delicate, and elastic, normally and necessarily so in order to allow of free excursions of the neck and chin. This skin, especially in childhood, is easily destroyed, when the dense scars which supplant it contract often into limiting bands which depress the chin, control cervical rotation, and hold open the mouth in a distressing, disfiguring, and humiliating fashion. The treatment oi this condition is by no means easy. It does not suffice to cut away the bands, for new cicatrices then form. The surgeon must turn up great flaps, exposing considerable areas of raw surface, before the normal movements of the chin and neck can be restored; and he must then fill in the raw surfaces with flaps of true skin taken from the chest, shoulders, or sides of the neck. The chest skin-flaps are best, for skin from the chest is elastic and allows of ready stretching into place, while the consequent gap left on the chest can usually be filled in by drawing over it adjacent skin or by applying Thiersch grafts. TORTICOLLIS Torticollis, or wry-neck, is another distressing affection of the neck, but not so grievous generall}- as the cicatricial deformity. There are sundry forms and causes of torticollis : cicatrices may cause it^ of a nature 586 TORTICOLLIS 587 similar to those already described; articular torticollis is due to an inflaniniation of the vertebral joints, and falls to the care of the ortho- pecUc surgeon for treatment by apparatus; muscular torticollis is seen in new-born infants, born by the breech, and is the result of partial rup- ture of the sternomastoid fibers. A hematoma, suggesting a tumor mass, appears shortl}', but the disablement is readily curable by simple surgical measures — bandaging and the wearing of a supporting collar. Spasmodic torticollis interests us especially, though little advance in its treatment has been suggested since the publication of Walton's admirable paper in 1898.^ Ml Fig. 387. — Cicatrix from burn. Personal case (Massachusetts General Hospital). As Walton says, " spasmodic torticollis is a disorder of the cortical centers for rotation of the head." The pathogeny of the disorder is not altogether apparent, but symptoms of neurasthenia, and more rarely of hysteria or mental disease, may be associated with the ailment. The victims are commonly between thirty and fifty years of age, though young persons are not exempt. The patient may appear normal upon one's first inspection, but some slight irritation, not always obvious, brings on a spasm of muscles, throwing the head to one side in a painful, distressing, and somewhat ludicrous fashion. The muscles generally affected are the sternomastoid and trapezius, more rarely the splenius capitis, the complexus, the trachelomastoid, and the inferior oblique. 1 G. L. Walton, Amer. Jour. Med. Sci., March, 1898. 588 THE FACE AND NECK In most cases the spasm attacks the sternomastoid of one side and the posterior rotators of the other, so that these two grou])s of muscles combine to rotate the oc('ij)ut and give the chin an u])\vard tih. Karely both sternomastoids alone are affected, or, still more rarely, the pos- terior rotators of both sides. You can do little for these cases Avith drugs, electricity, massage, and similar remedies, though occasionally a confining collar will give the patient the desired comfort. Nor are operations altogether satis- factory, and such operations as we can do vary greatly in their severity from simple nerve-stretching to extensive tenotomies. If an opera- Fig. 388. — Spasmodic torticollis (Massachusetts General Hospital). tion be undertaken, therefore, it is good practice to resect first the spinal accessory nerve on the affected side, in the hope that this will relieve the symptoms. Should this operation fail, the surgeon may pro- ceed to the more radical division and avulsion of the posterior branches of the three first spinal nerves on the opposite side (Keen) ; or even to tenotomies of all the muscles affected (Kocher). After the operation the patient's head should be supported for at least three weeks in a well- fitting Thomas collar, and the surgeon must attend specially to the patient's general condition, directing careful massage, suitable tonics, an out-of-doors rest-cure, or a long vacation. Persistence in these CERVICAL ADENITIS 589 measures will often relieve completely the sufferer; and the destruction of nerves and muscles, even, may be so far recovered from as to leave the patient with a useful and sightly neck. CERVICAL ADENITIS Cervical adenitis furnishes frequent occasions for operations u])on the neck. The lymphatics of the neck drain a region peculiarly Fig. 389. — The lymph-nodes of the neck (Campbell). susceptible to infection, and for this reason the nodes of the neck, more than any other group of nodes in the body, are wont to be found enlarged. Anatomists divide the cervical lymphatic nodes into two sets, the super- 590 THE FACE AND NECK ficial and the deep — those immediately below the platysma, and those resting upon the carotid sheath. For the clinician, however, no such invariable division is possible; the lymphatic channels communicate freely with each other, and infections of nodes, both superficial and deep, frequently coexist. Observe the interesting fact, recently pointed out by Crilc: the lowest cervical nodes in the region of the clavicle .seem to act as a collar or barrier, below which malignant processes extend slowly and late — malignant as compared with inflammatory involve- ments. The latter extend early below the clavicle. For the surgeon, then, dealing with cervical adenitis, the important nodes are those immediately behind the posterior belly of the digastric muscle, the nodes Ij'ing upon the carotid sheath, and those in the posterior cervical triangle. (See Chapter XX.) Be it noted, however, that the super- ficial cervical nodes communicate freely with the axillary nodes, while the deep cervical nodes are associated with the nodes of the mediasti- num. When discussing malignant disease of the mouth, I pointed out that the buccal cavity, the tongue, and the lips drain into the cervical lymph-nodes. For this reason infections in the mouth set up inflam- mations in, and result in abscesses of, the neck; but the most impor- tant source of infection, as concerns the cervical nodes, is the tonsils. Especially does this appear to be true of tuberculous invasions, so that the surgeon, w^hen confronted with a case of tuberculous cervical adeni- tis, should examine invariably the tonsils, and whatever be his treatment of the swollen neck, he should correct the lesion in the throat. Children most commonly are sufferers from lymphatic infections of the neck, — infections especially of the tuberculous type, — but these diseases attack persons of all ages and of both sexes. In the old days these tuberculous patients w^ere called '' scrofulous," and the ailment was dubbed " scrofula." Such patients may present that typical, hectic, anemic appearance which we associate with victims of tubercu- losis; but the typical appearance is by no means the rule. We find tuberculous nodes in the necks of robust-looking men. Most of the patients, however, appear ill. They are anemic ; their appetites are poor, and they are often emaciated. Frequently the}- have fever, with a temperature ranging between 99° and 101° F. Such patients will tell you that they have been running clown for a long time, and that, as a result of being rim down, lumps have appeared in their necks. On ex- amination the surgeon may find enlarged nodes in the axillse and groins also, but in the neck especially, on one or both sides, he will find swellings, large or small, multiple or single, hard or fluctuant, sometimes resemb- ling a chain of marbles lying on the front of the sternomastoid, some- times presenting a single ovoid tumor under the angle of the jaw and as large as a man's fist. Frequently there is a history of recurring at- tacks of " swollen glands," enlarging and subsiding, with corresponding fluctuations in the patient's general health. Sometimes one finds pul- monary disease or evidence of tuberculosis within the abdomen or joints, but we are not dealing here with such complications of cervical adenitis. The treatment of tuberculous cervical adenitis is not at all a simple CERVICAL ADENITIS 591 matter, and the treatment has varied greatly in the past fifteen years. At times it has been the custom to poultice the swelling and to open and drain it after it has ripened into an abscess. That is bad treat- ment. We recognize now the importance of eliminating those tubercu- lous masses as early as possible, lest they serve as foci for the spread of a general tuberculosis. But elimination of lymphatic tuberculosis does not always and necessarily imply incision. Yer}- many of these persons will recover sound health under a careful regime and a per- sistent out-of-doors hfe. Unfortunately, numbers of the poor patients seen in large hospital clinics cannot secure the proper out-of-doors treat- ment, so that surgeons often become weary and skeptical in advising such a course. That skeptical attitude of the surgical mind is irrational. No theory of therapeutics is more certain and well established than that a great majority of cases of tuberculous adenitis will recover if they can pursue faithfully and uninteriTiptedly for six, eight, or twelve months a proper life in the open air. One must supplement this course by an abundance of good food and such tonics as iron, malt, and the various forms of fats. There will remain, however, a considerable proportion of patients who either cannot secure the out-of-doors treatment or fail to recover under that treatment. For some of these persons therapeutic injections of Koch's new tubercuhn may be appropriate, injections ad- ministered under, and controlled by, the opsonic therapy of A. E. Wright. There remain finally the large number of cases which must look for relief or cure through a surgical operation. Operative treatment of tuberculous adenitis concerns itself naturally with two classes of cases, according to the nature or extent of the in- flammatory process: (1) There are the hard and nodular masses. It is a simple matter to cut down upon, isolate, and excise these masses, which have not suppurated or become caseous. (2) There are the abscesses. It is impossible to excise thoroughly tuberculous disease which has advanced beyond the node capsule, has invaded neighboring structures, and involved generally the soft parts of the neck in a degenerative process. Briefly, the nodes which are still intact should be removed totally, so far as may be. Small masses of nodes in the upper part of the cervical region may be reached by Bollinger's method, which consists in making a curved incision along the line of the hair, starting from just behind the ear. The advantage of this method is that it leaves no perceptible scar; but it is not a satisfactory method by which to reach thoroughly aU parts of the neck. It is a burrowing and somewhat blind performance, but I admit that I have found it useful in a few selected cases. Other groups of nodes, relatively small, may well be reached through a trans- verse incision at any level of the neck, and I recommend this incision in suitable cases, for it follows the natural line of cleavage of the skin, and there results an insignificant scar. There will remain always those more extensive and involved cases presenting masses of nodes filling the whole neck from the jugular fossa down to and below the clavicle, and extending widely into the posterior cervical triangles. To remove 592 THE FACE AND NECK these nodes necessitates an operation often as far roaehino; and crippling as the extensive block dissection of the neck for cancer — indeed, the description of these block dissections in Chapter XX of this book may be made to apply to extensive dissections of tuberculous disease, but with this difference, that tuberculous disease of the neck does not often in- volve other than lyni]:)hatic structures, so that the surgeon is not forced to remove muscles, vessels, and nerves even. Rarely, I have been obliged to excise a tuberculous sternomastoid muscle, but, as a rule, one can find abundant room for the dissection by cutting through and turning back out of the field the sternomastoid, to be restored carefully with stitches at the close of the operation. It is well, in dissecting out great masses of nodes, and after having turned back the skin-flaps and sternomastoid, to begin at the clavicle and work upward, making a clean Fig. 390. — Scarless method for removing enlarged cervical nodes (Bollinger). sweep of all the involved nodes to the last one, which is usually found almost as high up as the jugular fossa. Writers divide somewhat fanci- fully the groups to be removed/ discussing special maneuvers for special groups. It is true that enlarged nodes tend to follow well-defined planes of least resistance, that certain groups tend to remain limited to the digastric region and others to the carotid region, but it is imjDossible to assign all cases to definite classes. In general terms, however, the surgeon should attempt to follow Sutcliffe's three rules: (1) The operation should be as complete as possible; (2) the spinal accessory and other important nerves with the vessels should escape injury; (3) the incision should be planned so as to make the resulting scar as little visible as possible. 1 W. G. Sutcliffe, Brit. Med. Jour., May 13, 1905. WOUNDS OF THE THORACIC DUCT 593 Our discussion of the opcnitivc treatment of cervical adenitis hith- erto has dealt with the removal of encapsulated masses. It remains to say a word regarding tlie broken-down, suppurating nodes involved in mixed infections. These inflamed nodes and the resulting abscesses are those which " point" beneath the skin, break through, and discharge externally, and in their healing leave those ugly scars of the neck with which we are all familiar. If a limited abscess has formed without ex- tension to other nodes, it may be tapped, washed out, and drained through a fine cannula,^ which should remain in place for about a week, when it may be removed, and the little sinus allowed to heal. An im- perceptible scar usually results. Extensive, suppurating, burrowing tuberculous disease, on the other hand, must be opened thoroughly, Fig. 391. — Small transverse incisions. cureted, the deep parts painted with iodin, and the wound packed and drained, with a resulting ugly scar. Such, in general, are the methods of treatment applicable to tuber- culous cervical adenitis. The surgeon should remember always that after an apparent cure these patients are still subject to reinfection, and should be taught carefully the importance of leading properly regulated lives, under the best obtainable surroundings. WOUNDS OF THE THORACIC DUCT Wounds of the thoracic duct are reported from time to time, and every surgeon who has occasion to dissect extensively the deep tissues ^ Briggs' cannula. 38 594 THE FACE AND NECK of the neck probably has been guilty of damaging this important struc- ture. I have myself wounded the duct twice. Some years ago Allen and Briggs collected 17 cases from the reports of various operators.' Fortunately, the lesion heals in most cases without great trouble or special care. The wound in the duct cannot often be repaired, though sometimes it may be found and sutured. Allen's fourth conclusion is important — " until repair of the duct is thought to be complete, nutrition should be sustained on albuminous material, with possibly a small amount of carbohydrates, but with an absolute exclusion of fats." DEEP CERVICAL ABSCESS Deep cervical abscess is a serious condition, which may simulate or be confused with suppurating lymph-nodes, but the deep abscess to which I refer owes its origin to an inflammation of other structures, such as the parotid gland, the submaxillary gland, or the cervical vertebrae. These deep abscesses burrow far, and, following the fascia down the planes of the neck, may reach the chest and cause the most serious kind of trouble. Such abscesses, therefore, may be regarded generally as " cold abscesses."- They are painful; they are extremely tense; they are associated with a moderate rise of temperature; they cause pro- found prostration, and thej^ must be treated by incision and drainage as soon as they are discovered. Some of them, located high in the neck and observed early in their course, may be cured after tapping by the injection of iodoform glycerin (3 drams of iodoforai to 3 ounces of glycerin), but this maneuver has its dangers. It may not check the disease, in which case the abscess must be opened freely and drained as though de novo. PEDICULI CAPITIS Pediculi capitis (head lice) often cause infections of the supei-ficial lymph-nodes posterior to the sternomastoid muscles. A soft abscess in the region of the mastoid process, especially in an ill-kempt child, always should prompt the surgeon to examine the patient's head. Often he will find in the hair lice associated with a diffuse dermatitis. The treatment consists not only in opening the abscess, but in making the proper applications of crude petroleum to the head in order to destroy the parasites. LYMPHATIC CYSTS Lymphatic cysts (one form of " hydrocele of the neck") are some- what uncommon congenital cysts, which appear on one or both sides of the neck, usually anterior to the sternomastoid muscles. Rarely they may extend into the axilla or chest. They may be monolocular or multi- locular. They originate beneath the deep fascia, but ))ortions of them may become subcutaneous. They are thin walled and contain a translu- ^ Dudley P. Allen and C". F]. Briggs, Amer. Med., September 14, 1901. 2 " Cold abseess," usually a chronic abscess forming slowly witliout marked inflammatory sjonptoms; or sometimes a collection of pus remote from its .source of origin, e. g., psoas abscess in the groin, the result of inflammation of vertebrte. THK CAROTID GLAND 595 cent serous fluid, which often gives them the appearance, when inspected through the hych'oscope, of scrotal hydrocele. Hydrocele of the neck appears in children; rarely it persists after the fifteenth year. It dis- appears spontaneously as a result of inflammatory or atrophic changes. These cysts may be aspirated and the sac injected with a 5 per cent, solution of carbolic acid — at once removed; or they may be left for a spontaneous cure. THE CAROTID GLAND i There lies in the fork of the carotid artery, where it divides into its external and internal branches, a minute structure, varying nor- mally in size from 4 to 7 cm. in length, which recently has become the subject of active surgical in- terest, for it ma}' take on malignant changes, may enlarge so as to disfig- ure the neck, and may cause distress- ing symptoms, ^^on Haller, in the middle of the eighteenth century, described the carotid gland, but not until 1S91 was it recognized as a possible seat of tumors.- In 1906 Keen had coUected 27 cases, and numerous other cases have been re- ported. Tumors of the carotid gland ap- pear in persons of all ages, though the}' are most common in early adult Hfe, and are divided equally between males and females. The ordinary tumor of the carotid gland grows slowly and appears first as a smaU lump, a little larger than an alrhond. It reaches a considerable size and is ovoid and firm, with a well-defined capsule closely adherent to the vessels; while its substance, divided by numerous septa, is brown or broT\Tiish-red on section. It is fed constantly by a small arteiy from the internal carotid. TMiile there is still a variety of opinion regarding the structure of the gland, it appears that the essential elements are blood-vessels and cells; and among the cells and in the stroma there are elements to which have been applied the terms " chromophile" and '' chromofiffine," to which 1 W. W. Keen and John Funke, Tumors of the Carotid Gland, Trans. Amer. Med. Assoc, section of Surgeiy and Anatomy, 1906. This is the most comprehensive .and satisfactory article as yet published on this interesting subject. - IMarchand, Virchow's Festschrift, 1891, vol. i. Fig. 392. — Carotid gland, showing the three carotids and their relation to the tumor (Scudder). 596 THE FACE AND NECK are attributed an im])ortant functional significance similar to that as- cribed to elements in the suprarenal glands. " Mulon concludes that the chromafiffine cells secrete a substance which, when introduced into animals, acts like adrenalin in raising the arterial i)rcssure."^ The tumor is always intimately associated with the carotid vessels, and cannot be separated from them with safety. By its pressure it may encroach upon, or ol:)literate even, the artery's lumen. A patient with one of these growths suffers little discomfort until the tumor has reached a considerable size. Rarely is there pain, dysp- nea, or involvement of the sympathetic and pneumogastric nerves sufficient to cause changes in the pupil or in the heart-rate. The tumor may grow slowly for many }'eai's and then increase ra])idly in size, so that the patient seeks relief for the deformity rather than for any actual discomfort. When the surgeon comes to examine one of these growths, he may mistake it readily for an enlarged Ij-mph-node. The tumor lies under the sternomastoid muscle and presents a long, ovoid swelling in the line of the muscle, a swelling movable laterally, but not up and down. The skin is not discolored or adherent, and a transmitted pul- sation, without thrill or expansile impulse, can be felt. In their early stages these tumors are not malignant, though prompt removal may be followed by apparent recurrence, probably, as Keen says, from micro- scopic rests W'hich were overlooked. Later, with the development of the tumor, the histologic elements undergo marked and peculiar modi- fications, resembling somewhat those changes seen in the so-called hyper- nephroma. For the sake of a word, and in order to define the clinical status of the larger tumors of the carotid gland, it would not be im- proper to group them with the endothcliomata (Fur>ke). With this understanding of the clinical characteristics, the progress, and the nature of carotid gland tumors, the surgeon ma}- be able to make a correct diagnosis, and should proceed guardedly to advise — Treatment. — It is an interesting fact that the removal of these tumors is not the easy, safe, and curative process one would expect. The death-rate from operation is about 25 per cent., so that it is best to operate only in the face of serious functional troubles or the rapid evolution of an apparently malignant growth. In operating, and after exposing fully the growth, the surgeon should isolate it carefully from all neighboring nerves and other adjacent stnictures with the ex- ception of the carotid vessels. He cannot safelj' separate it from these vessels. Then he must ligate the carotid artery and its two main divisions above and below the tumor, divide the arterial trunks, and remove the growth with the included vessels. If the ])atient surviA-e the immediate .shock of the operation, recovery should be prompt and uneventful, and the convalescence be completed within ten days. I have elaborated this subject of the carotid gland perhaps unduly on account of the novelty and recent interest in the matter. Another subject for surgery in the neck, a condition shown bj^ skia- graphs to be relatively common, is the cervical rib. 1 Keen and Funke, ibid., p. 60. DISEASE OF THE THYROID GLAND 597 CERVICAL RIB This abnormality is not a true rib, but is a peculiar lengthening of the transverse process of the seventh cervical vertebra on one or both sides. No symptoms or special discomfort commonly are caused by a cervical rib, so that the patient may go through life without knowl- edge of this peculiarity in his anatomy. Occasionally, however, tor- sion of the subclavian artery may be caused by the rib, resulting, per- haps, according to G. Fisher, in subclavian aneurysm. The more com- mon changes, however, are trophic, with an ischemia and consequent necrosis of some of the parts supplied by the artery affected. W. W. Babcock "■ reports an interesting case of this sort in which the right hand was cold, pulseless, and numb, at times, and affected by ulcers, with gangrene of three fingers. Excision of a cervical rib on the cor- responding side cured the disorder. We come now to a discussion of the most hotly debated, difficult, interesting, and promising subject in the whole field of surgery of the neck, namely, affections of the thyroid gland. DISEASE OF THE THYROID GLAND Goiter is the common and important disease of the thyroid gland, and I suppose goiter shares with cancer and '' stone" the honors of literature — history and fiction. Goiter has always been regarded as a disease peculiar to mountain folk, and the Swiss especially are notable as victims of this growth. It is not surprising, therefore, that we find in Theodor Kocher, of Bern, the most eminent exponent of this in- teresting theme. You will see in all the old surgeries the striking pictures of goiter, enormous tumors of the thyroid gland, as large as a man's head or larger. These are the classic pictures. Nowadays, thanks to the activities of surgeons, such great goiters rarely are seen, for we have learned how to combat the disease, have ascertained that many forms of goiter are amen- able to medical treatment, and that the rest generally may be removed with safety. Two facts regarding goiter, interesting to surgeons es- pecially, have been demonstrated in recent years: (1) That lying behind the lobes of the thyroid one finds four or more minute bodies, the size of small peas, and known as parathyroid glandules, the presence or absence of which has an extremely important bearing on function and on life; and (2) that that curious disease, exophthalmic goiter, first described by Graves in 1835, often may be cured by a surgical operation. These and kindred matters we shall discuss shortly. Let us now consider systematically, but briefly, some of the details and conditions of the natural history and treatment of disease of the thyroid gland. The gland — a ductless gland — is a horseshoe-shaped organ, lying across the trachea immediately below the cricoid cartilage; one lobe of 1 Amer. Med., October 7, 1905. 598 thp: face and neck Qo^^l-/ the gland on cither side of the trachea, the lobes connected by an isth- mus. This is the normal, commonly accepted descrij^tion, but the gland varies greatly in appearance. Often it is dumV^-bell shaped. Often there springs from the isthnuis and runs upward in the middle line of the neck toward the hyoid bone a third lobe, or })}-ramidal process. Albert Kocher states that this pyramidal process, round and worm-like, is found in most thyroid glands, that it varies greatly in length, and rarelv extends to the hyoid. The thyroid gland develops out of the ventral wall of the phar3'nx from a median proliferation. Observe then this important fact — this pi-oliferation, or ductus, may fail to become ob- literated, wdth the result that wandering or accessory thyroids are formed, usually trifling affairs, quite isolated from the main gland. One finds them above or below^ the hyoid, or in front of, or behind, the trachea. The wandering th\'roids are to be distinguished carefully from the parathyroids. Parathyroids. — Wandering thy- roids may develop tumors and goiters in unexpected positions. Parathyroids are stinictures of quite different origin and function from wandering thyroids. Parathyroids develop from the third and fourth bronchial pouch, and are constantly present in man. Generally, there are four parathyroids, — two upper and two lower, — so that they are, as it were, placed in pairs on either side of the trachea, embedded in loose connective tissue behind the thyroid gland itself. The tissue in which they lie is derived from the deep cervical fascia, and is known as the external thyroid capsule. Occa- sionally there exist wandering groups of parathyroid cells or glandules even, sometimes outside of the th3'roid gland and sometimes within it. The thyroid gland itself lies beneath the suix'rficial muscles of the neck, — the platysma, stemomastoids, sternothyroids, etc., — and is regarded as having two capsules — the loose external capsule of which I have spoken (which contains the recurrent laryngeal nerve) and the firm iimer capsule proper, which strips with difficulty and sends pro- longations between the lobes of the gland. As to the blood- and nerve- supply of the thyroid gland, suffice it to say that there are the two superior thyroid arteries and the two inferior thyroid arteries, with occasionally the thyroidea ima. The veins of the gland spring especially from the region of the isthmus, are exceptionally large and numerous, and the gland is extremely vascular. The nerves are derived from the Fig. 393.— The thyroid gland: A, A, The lobes; B, the isthmus; C, the in- constant middle lobe (Campbell). DISEASE OF THE THYROID GLAND 599 superior ganglion of the sym])athetic and from the lar5Tigeal branches of the pneuniogastric, and they accompany the blood-vessels. The thyroid is a ductless gland, normally reddish or yellowish red in color, the cut surface finely granular and exuding in considerable amount a col- loidal material — a clear, yellowish, slightly sticky fluid. The gland sub- stance is made up of closed tubules, each containing the colloid material, completely filling the tubules or follicles. The wandering thyroids have a structure like th^t of the thyroid, but the parathyroids have a structure quite different — a thin, connective-tissue capsule sending out fibers into the substance of the little gland, with a stroma containing blood-vessels and lymph- vessels, and a protoplasm, either granular or clear. A few words about the functions of the thyroids and parathyroids. As Albert Kocher states, " the high iodin-content of the thyroid gland is its most characteristic feature, and the iodin-containing albumin of the gland (iodothyrin) is capable of replacing the thyroid secretion. The amount of iodin in the gland usually is proportional to the kind and quantity of colloid material present. The secretion of the thyroid gland in some fashion enters the circulation, and we know that it exer- cises a metabolic function in the bod5^ Through some unknown chemical process the gland has a special influence on the nervous system and vas- cular system; the skin and epithelial structures; the bones and sexual organs." The parathyroid glandules have a function which is not so apparent, but the thyroid and parathyroids certainly act in conjunction and are not independent of each other. We may assert tiiily one important and negative function of the parathyroids. When present, they are antitoxic. Remove the parathyroids and the patient will fall a victim to tetany. . At least two parathyroids are necessary to sustain properly the function of these interesting organs. Before taking up a discussion of the ordinary enlargements of the thyroid it will be instructive to consider briefly those diseases which may arise from interference with the functions of the thyroid and para- thyroids. These so-called functional diseases are dependent upon suppression of the secretion or upon hypersecretion of the glands. Loss of the thyroid function produces sundry striking disturbances: the myxedema of cretinism, idiocy, disturbance of sexual function, neu- roses, psychoses, epilepsy. One sees that these ailments are due di- rectly to the loss of thyroid function, and the obvious treatment is to supply the loss.. The physician may hold the disease permanently in check by feeding the patient with preparations of thyroid gland, while the surgeon may succeed in improving or curing the condition by implant- ing in the individual, normal thyroid gland tissue, obtained preferably from man."^ The implantation of parathyroid tissue has not yet led us to definite therapeutic knowledge. Interesting as are the results of the loss of thyroid secretion, the results of excessive secretion are more interesting still. These cases of excessive secretion are grouped under the head of thyrotoxic diseases. ^ Albert Kocher, Keen's System of Surgery, vol. iii. 600 THE FACE AND NECK Thyrotoxic Diseases [Graves' Disease; Basedow's Disease; Exoph- thalmic Goiter; H i/pidism). — The cha,racteri«ti(' feature of these diseases is that the intoxication of the body is effected through hyper- phisia of the thyroid gland, so that, as we should expect, operations upon the gland are almost invariably followed l)y improvement in the patient's symptoms. The symptoms of Graves' disease are extremely numerous, and I shall sketch them in the briefest detail. The thyroid gland itself is enlarged uniformly, and one discovers in it a thrill, blowing murmurs, expansive 'v/». %-^ Fig. 394. — External appearance of exophthalinio goiter (Massachusetts General Hospital). pulsation, and enlargement of the artei-ies. The growth is usually soft, and there is loss of elasticity. The pulse is rapid (tachycardia) and of high tension, with commonly an increased blood-pressure. Slight capillary hemorrhages are frequent. You will observe tremors of the hands and feet, of the eyelids and lips. Bulging of the eyeballs (ex- ophthalmos) occurs in acute cases, with lagging of the lids. The skin is moist, the hair drops, the nails crack, there are frecjuent pigmenta- tions of the skin, suggesting Addison's disease. Diarrhea is common, and there may be nausea and vomiting. There are great lassitude and emaciation, while the menstrual flow diminishes or ceases entiiely, DISEASE OF THE THYROID GLAND GOl and {'hiiracteristic blood changes occur. Such arc a few of the symp- toms. Tlie disease may be acute or chronic, with acute exacerbations, but we need not folIo\\' its numerous and manifold terms further than to observe that if it develops suddenly, the course is more grave, and the prospect more gloomy than when it begins slowly. With these brief ob- servations on the nature of Graves' disease let us consider its treatment. Regarding the treatment, the most active and diverse views are still held. Many internists have pointed out that almost any treatment or no treatment at all will result in alleviation or even cure, while others, advancing upon more rational lines, have secured some benefit from serum therapy. On the other hand, surgeons, with increasing show of reason, are claiming and demonstrating that resection of the offend- ing gland gives the greatest percentage of cures. I need not here con- sider at length the interesting problems of serum therapy, but refer the reader to the valuable contributions of S. P. Beebe and John Rogers.^ Of surgical treatment, Albert Kocher remarks: " To say that this is still the best is not enough. It has proved itself superior to any other form of treatment." C. H. Mayo also, in a series of convincing articles, and drawing upon a great experience, has demonstrated the value of these operations. All cases of exophthalmic goiter must not be submitted indiscrimi- nately to operation. Immediate operation should not be done in those cases which show advanced cardiac changes, irregular pulse, low blood- pressure, or periodic attacks of delirium cordis. In such cases the subjects should be submitted to x-raj exposures and belladonna intern- ally for a few days or weeks previous to the operation. Moreover, it is well in such cases to perform one or two preliminary ligations of the superior thyroid arteries. Indeed, we believe that in certain severe cases of Graves' disease the operation should be performed in one, two, or three sittings, beginning with tying the thyroids. The rest of the opera- tion must depend upon the course of the disease and the condition of the enlarged gland ; in the case of great enlargement, one should remove the more vascular half of the gland with the isthmus and pyramidal process. Under no circumstances should one remove the whole thyroid. In quite early cases it may suffice for a cure to ligate two or three of the thyroid arteries, and in all cases of resection of the gland the sur- geon must avoid especially damage to the two lower parathyroids at least." The operation of thyroidectomy generally is more difficult in Graves' disease than in the ordinary forms of goiter, for in Graves' disease the vascularity of the tumor is greater, the vessels are more easily torn, the external capsule is more adherent, and the interstitial tissue is more 1 S. P. Beebe, Jour. Amer. Med. Assoc, February 17, 1906, and Trans. Amer. Med. Assoc, 1907. John Rogers, Jour. Amer. Med. Assoc, February 17, 1906. See also important paper by James M. Jackson and L. G. Mead on the value of hydro- bromate of quinin, Boston Med. and Surg. Jour., March 12, 1908. - See G. W. Crile's important obser\-ations on the Psycliic Aspects of Graves' Disease, Trans. Amer. Surg. Assoc, 1908, p. 391. 602 THE FACE AND NECK brittlo; and these are additional reasons for the occasional i)i'eliniinaiy ligation of vessels. 1 shall have to speak further of the technic of the operation when discussing goiter proixM-. Until recently section of the sympathetic nerve occasionally has been done as a therapeutic measure in Graves' disease, but this operation now is generally abandoned. One need not often fear extensive toxic symi)tonis following thyroi- dectomy, especially if proper drainage be instituted for twenty-four hours, and if two parathyroids at least are left. In most of the cases the improvement in the patient's general condition is prompt and striking. He becomes quiet, his eyes appear less wild, the ])ulse-rate falls, tremor disappears, and within a very few days convalescence is established — conditions which contrast markedly with the results of the dreary, prolonged, and uncertain treatment of former times. GOITER 1 Writers still speak of goiter as struma, but to the student of etymol- ogy it is interesting to observe that struma means ]M-imarily scrofula, and secondarily goiter. Scrofula, in the modern acceptation of the term, means anything but goiter. Let us admit then that goiter signifies an enlargement of the thyroid gland, and let us eschew the confusing term struma. Students of the subject still debate the question of the classi- fication of goitre, but I believe we shall make no mistake in adopting the classification of Kocher, bearing in mind always that goiter is a benign disease, not to be confused with inflammatoiy swellings of the gland or with malignant thyroid tumors. We divide goiter into two main varieties — diffuse goiter, in which the entire gland is involved, and nodular goiter, in which portions onh- of the gland are affected. Diffuse goiter occurs in six well-recognized forms: (1) Hypertrophic follicular goiter, a genuine hypertrophy of the whole gland, involving an increase of all its elements; (2) parenchymatous goiter or adeno- matous goiter, in which the e])ithelial cells only are increased in number and size ; (3) colloid goiter (cystic goiter) , due to a stretching or enlarge- ment of the follicles, which become distended with colloid material — this is by far the most common form of diffuse goiter; (4) vascular goiter, characterized by marked vascular changes, the arteries especially being greatly increased in volume. The other elements of the gland multiply also, but the vascular changes are the most conspicuous; (5) fibrous goiter, a rare condition, due to inflammation and excessive development of connective tissue; (6) recurring adenomatous goiter, marked by the new formation of small follicles, and resembling adenoma. Such growths are properly malignant, so that the term adenoma malignum is employed also. This is an extremely rare form. Nodular goiter also has its six forms, corresponding to those of diffuse goiter, but portions or small areas of the gland only are involved. In ^ Goiter: French, goitre; Latin, guttur — the gullet, the throat. GOITER 603 nodular goiter also increase of colloid material gives us the most promi- nent type, as in variety number three, already described. Surgeons speak of cystic goiter: this form is properly colloid goiter, and the ap- parent cysts are the distended follicles filled with colloid material. The reader will readily conceive how various ma}" be the external ap- pearances of goiter, depending upon the size, location, and multiplicity of nodules. Single isolated nodules are rare. Sundiy degenerations take place in goiter, with the formation of new tissue which may also suggest at times teratomata. The enlarging gland, if undisturbed by treatment, will continue to grow indefinitely, as a nde, though after the patient's fiftieth year many goitei"s tend to shrink unless infianmiation or malignant changes supervene. Fig. 395. — Cystic goiter (TMassaehusetts General Hospital). Goiter may cause a great variety of symptoms, depending upon variations in rapidity of growth, in location of the nodules, and in his- tologic stiiicture. For a long time there may be no SATuptoms. and the patient will complain of the deformity only, or there may develop var- ious s^Tnptoms due to pressure. Distortion of the trachea may impede the breathing; pressure on the recurrent lar^Tigeal nerve may cause hoarseness; the enlarged gland may push down into the thorax and alter the size and relation of blood-vessels, and the student should always remember the possibility of aberrant th^Toids taking on goiter formation and developing puzzling tumors in unexpected localities — for instance, beneath the chin and at the base of the tons;iie. 604 THE FACE AND NECK We recognize six important facts in establishing the diagnosis of goiter: (1) The position of the tumor on the fi-ont of the neck, Ix'low the larynx and between the sternomastoid muscles; (2) the up-and-down movement of the tumor during deep respiration, and especially during the act of swallowing. If a large, deeply adherent goiter fails to move with these tests, a vigorous cough will cause the mass to protrude, and this cough test is especially useful in the case of intrathoiacic goiters, which ordinarily are not readily visible or palpable; (3) note the easily recognized normal gland shape of the diffuse goiter, and the irregular appearance of a nodular goiter; (4) a goiter not fixed by infianmiation vaay be moved about readily; (5) percussion and auscultation are most useful in the case of deeply placed goiters, for then one discovers char- acteristic dulness behind the sternum and dulness along the larynx and trachea, with diminished tracheal breathing in the side on which the goiter lies; (6) the superior thyroid artery and the great vessels of the neck often are pushed upward and outward by the tumor, so that these vessels become palpable. The investigator should not overlook disturbances of the heai't's action — disturbances which are common in goiter and are of grave im- portance often. We speak of goiter heart, which may be due to inter- ference with the trachea, with the blood-vessels, or with the pneumo- gastric nerve. Such a goiter heart must not be confused with the toxic goiter heart or tachycardia of Graves' disease. In this necessarily brief article we cannot well study in detail the various manifestations of different forms of goiter; but sufficient has been said to enable the student to distinguish the three leading types — diffuse hypertrophic goiter, nodular adenomatous goiter, and cystic goiter. The causation and frequency of goiter are subjects of interest sufficient for chaptei's of their own in the large surgical monographs. Suffice it here to point out that our general belief regarding the cause of goiter has not changed during the last three generations. The cause appears to be some peculiarity of drinking-water derived from the soil through which it passes; and the peculiarity of such water is believed to be a qualitative change in the iodin which it contains. No countr}^ is entirely free from goiter subjects, though the disease is especially constant or endemic in certain countries, generall}- mountainous. These cases of endemic goiter are generally of the colloid variety. Certain it is that improvements in water-supply have made the disease less fre- quent in famous goiter regions. It is a fact familiar to surgeons that in great numbers of cases internal medication suffices for the treatment of goiter. With medicine, how- ever, we need concern ourselves no fuither than to state that iodin is the one reliable drug for the relief of goiter. At one time experienced ph}- sicians maintained that 90 per cent, of all cases of goiter could be cured by iodin. This is probably incorrect, but the percentage is still large. The iodin may be given in the form of potassium iodid or in some of the forms of " soluble iodin," or the thyroid gland extract may be employed^ GOITER 605 although this in effect is but a form of iodin administration. We have to deal with the operative treatment of goiter, and may note accordingly the following conditions in which internal medication is not appropriate: (a) Nodular goiter undergoing degeneration — a condition recognized as gelatinous, fibrous, calcareous, hemorrhagic, and cystic; (b) diffuse colloid goiter, which may be attacked with iodin, but usually must be referred to the surgeon; (c) goiter causing pressure symptoms and car- diac symptoms; (rf) abnormally situated goiter, especially when it projects into the thorax; (e) goiter developing suddenly and growing rapidly, and (/) an}- goiter which is sensitive to pressure or spontaneously causes pain. On the other hand, there are certain goiters which cannot safely be removed by operation — those which cause long-standing respiratory and circulatory disturbance, with impairment of the vital functions. Nor should one operate for goiter in persons with other serious organic derangements. The operations are various, and the following six methods of operating are practised : (1) Excision; (2) enucleation; (3) resection; (4) combined methods; (5) exenteration; (6) ligation of arteries. It seems needless to take up in elaborate detail these various methods, but the surgeon should have clearly in mind one method at least, the most useful and the most frequently applicable — excision.^ Certain considerations appty to all forms of operation upon goiter. The method of anesthesia has been frequentl}- and hotly debated. Kocher, Roux, and numerous other European surgeons employ local cocain anesthesia almost invariably, and claim that in thus dealing with a sensitive patient they avoid damage to nerves. One notes, however, that Kocher reports with satisfaction using general anesthesia upon his first 900 cases. English and American surgeons commonly use chloro- form or ether for general anesthesia, and we hear little or no complaint of their results. We protest that the cocainized patients do suffer pain, that the surgeon operates more comfortably upon a profoundly anes- thetized patient, and that, with reasonable care, he should avoid damage to nerves. In a considerable experience I have seen no reason to abandon my own preference for ether anesthesia. The patient should be placed in a nearly upright position, with the head strongly extended over a roller, and the pneumatic suit should be put on ready for use in case an extensive operation is undertaken, or when there is reason to suppose that shock or hemorrhage is to be combated. Kocher's method of excision or a modification of that method is the one most of us follow, and the student should remember always that ex- cision means the removal of part of the gland only. Total extirpation of the thyroid gland and parathyroid glandules is absolutely unjustifiable, for such extirpation means tetany and death for the patient. Make a transverse crescentic incision from sternomastoid to sternomastoid. One cannot have too much room in which to work. Turn upward the 1 For an excellent description of the common operations for goiter I refer the reader to J. F. Binnie's luminous article, Manual of Operative Surgery, third ed., pp. 212 to 221. 606 THE FACE AXD NECK skin and platysma, ox])osc the stenujliyoid, .steinothyroid, and omohyoid muscles, divide them if necessary (they should be sutured into place later) , and open transversely the external capsule of the goiter. This is the loose fibrous capsule which readily may be ])eeled back in all dirtH-lions. At the same time the surgeon must be on tlie lookout for the frecjuent numerous large veins which pass from the capsule to the gland. These veins must be doubly hgated and divided. Now dislocate the goiter and pull it out of the wound, by this maneuver relieving pressure from the trachea. Before dislocating the goiter the surgeon must warn the anesthetist. ;?:^ *J'* Fig. 396. — Cystic goiter, dislocated inward. Note severed sternothyroid muscle in clamps. Next, doubly ligate carefidh" the superior thyroid artery and vein and divide them between the ligatures. Pull the goiter over toward the sound side, seek and find the inferior thyroid artery, which lies on the deep muscles of the neck, and tie it carefully — carefully, because close beneath it passes the recurrent laryngeal nerve. The thyroidea ima artery lies at the lower pole of the tumor and must be ticnl finally. The thyroid isthmus remains, and is readily dealt with by crushing with forceps and tying firmly with a linen ligatui-e. If there be any further attachments, they are those which hold the gland by its inner margin GOITER 007 with the trachea. Close at hand Hcs the recurrent nerve. It is well, therefore, not to rip off these attachments, but carefully to dissect away the goiter at this point, leaving perhaps a little thyroid tissue to protect the ner\-e. The operation is now completed — it is not difficult, as a rule. The surgeon imites with catgut ligatures the cut superficial muscles, and sews up the wound throughout, providing at the same time for abundant tubular drainage, the tube to be removed at the end of twenty-four hours. Such a description of thyroidectomy applies to removal of one lobe only of the gland. Frequently it happens that both lobes are extensively diseased or that the patient is the subject of exophthalmic goiter. In such cases the surgeon must remove a large part of the second lobe. He Fig. 39T -Operation of thyroidectomy completed, muscle. Sutures in stmnp and in leaves, for the sake of the thyroid function, a slice of gland adherent to the posterior capsule on one or both sides. By this maneuver he may feel sure that he is preserving also a sufficient number of parathyroid glandules. Before slicing off the thyroid he should tie securely the superior and inferior thyroid arteries within the substance of the gland. After removing the portion of the gland, it is well to cauterize with the Paquelin cautery the cut surface of the stump. After thyroidectomy patients generally make a prompt convales- cence. The modern operation should not be followed by severe symp- toms ; the patient should sit up on the third day and should be able to leave the hospital by the middle of the second week, with every prospect of permanent restoration to health. 608 THK FACE .VXD XEf^C Enucleation of f:;oitcr occasional!}' may be omploycd for the removal of nodules, especially when the other half of the gland is atrophied. Resection, after the method of v. Mikulicz, is useful in exceptional cases of diffuse goiter, especially when unilateral excision has been already performed or the timior is very large in both inferior homs. It is a rather dangerous and bloody operation, and must never be done in cases of Graves' disease. Exenteration (or marsupiahzation) means incision of the tumor and evacuation of its contents. Exenteration may be em- ployed when there are dense adhesions present, and in case of inflamed or malignant goiters, when a clean excision is impossible. Often we are forced to it in the case of intrathoracic goiter, especial!}- when there is Fig. 398. — The thyroid orland and ])arathyroid plandulr view) (Halted and Evans). -supply ( posterior danger of asphyxia and prompt relief is Imperative. Ligation of the thyroid arteries is a useful procedure in the case of extremely vascular goiters, and especially as a preliminary to excision of the gland in Graves' disease. Transplantation of the thyroid has been done in cases of myxedema and idiocy. The most successful case of this sort hitherto reported is that by Payr, to the German Surgical Congress in 1906. Payr implanted a bit ot healthy thyroid from the patient's mother in the spleen of a girl of six years. Both patients recovered from the operation, and the psychic condition of the girl was improved at the time of Payr's last report. Satisfactory as are operations for goiter, we must not lose sight of GOITER 609 the fact that the tumor may recur so long a.s the underlying cause of the goiter formation persists. A " recurrence depends upon whether the operator has removed the factors which influence the growth of the tumor" (A. Kocher). Diffuse hypertrophic goiters recur rarely as compared with nodular goiters. In general terms, however, we may assort that the recurrence of goiter is not common, but if compelled to operate upon such a recurrent tumor, we shall find difficulty often in dissecting through the mass of scar tissue and in leaving behind a proper amount of thyroid gland with the requisite parathyroids. The thyroid gland is subject to sundry other affections far less com- mon than goiter. Malignant disease occurs in the thyroid gland— rarely, in the normal gland, commonly in a gland the subject of goiter; so that we may prop- Fig. 399. — Colloid goiter removed by author, leaving posterior capsule and part of left lobe (anterior view) (f actual size). erly enough describe these growths as malignant degenerations of goiter. Sarcoma and cancer are the malignant tumors with which we are concerned. Sarcoma is far less frequent than is cancer — sarcoma of the spindle-cell variety, less often of the round-cell variety. These forms of sarcoma develop in nodular goiter and may be difficult to distinguish from lymphosarcoma. The tumor of sarcoma is soft and juicy. It attacks the walls of adjacent blood-vessels, and it undergoes softening. Metastases occur late, and the sarcoma kills slowdy. There are other forms of thyroid sarcomata — fibrosarcoma, osteosarcoma, and angiosarcoma so called. It is not possible always to differentiate these malignant growths from benign enlargements until the disease is far advanced. If metas- tases have not occurred, and if the sarcoma has not broken through the capsule proper, the tumor may be removed with a reasonable anticipa- tion that it will not recur. 39 61U THE FACE AND NECK EPITHELIAL DISEASES OF THE THYROID Epithelial disease of the thyroitl gland is a fairly common disorder. Kocher's classification includes the following 7 forms: (1) Genuine car- cinoma, which appears as a hard tumor, usually lobulated, the tissue opaque and dry, but tending to undergo softening, especialh^ when it develops in a goiter; (2) proliferating goiter or malignant adenoma, which occurs either in nodules or diffusely throughout the gland, while the gland invariabl}^ contains portions of tissue of the normal thyroid type. Proliferating goiter has a firm, compact feel and is not large; (3) metas- tatic colloid goiter. This is a rare and curious growth, resembling closely the well-known nodular goiter; (4) papilloma, which may be nod- ular or diffuse; (5) cancroid scjuamous epithelial cancer — an extremely Fig. 400.— Cancer of thyroid gland (Halstead). rare disease; (6) glycogen-containing epithelial goiter — a growth which develops in nodular goiter and grows rapidly. The cells are large and contain varying amounts of glycogen and large nuclei rich in chromatin; (7) small alveolar epithelial goiters, which are quite similar to the gly- cogen variety, except that the cells do not contain glycogen. Classes t and 2 are far the most common, and, when they occur, develop almost invariably in hypertrophic goiters and nodular goiters. These cancers are particularly interesting from the point of view of treatment. Often unexpectedly, one encounters them compHcating a goiter presumed to be benign. Thyroid cancer, like cancer elsewhere, is marked by two characteristics — metastasis and extension to surrounding structures. Unfortunately, the presence of these two features renders radical cure impossible, while the diagnosis is almost equally impossible before the EPITHELIAL DISEASES OF THE THYROID Oil development of these two features. For such reasons, if for no other, the goiter of a young adult should be removed if its growth cannot be controlled by iodin. And, further, the goiter of a middle-aged person invariably should be removed if it is seen at any time to take on a rapid growth, and particularly a rapid irregular growth. The treatment of malignant goiter by operation differs in no impor- tant essential from the treatment of benign thyroid enlargement by operation, except that malignant disease must be removed more search- ingly. Here again one encounters the problem of damage to the parathy- roids, and finds one's self on the horns of a dilemma. If one must choose between complete thyroid extirpation for cancer and partial thyroia extirpation for the sake of preserving parathyroids, one may be forced to concede that no operation whatever should be done. Fortunately, however, this predicament arises rarely, because operable carcinoma is confined usually to one side of the gland only. Far-reaching opera- tions, involving structures outside of the thyroid gland, have been done frequently, but with questionable results. Surgeons have removed portions of the trachea and the esophagus, with permanent relief in a few cases. In one desperate case of cancer of the thyroid involving the trachea I obtained a symptomatic cure and relief for six months by removing all involved tissue down to the tracheal wall, leaving the wound wide open, and exposing to the direct Rontgen ray the remnants of the .disease daily, and with enough persistence to keep up a mild derma- titis, following Crile's method. At the best, however, there is little hope for the cure of cancer developing in goiter unless the operation is done before the diagnosis of cancer is made. Aberrant goiter exists. There are two forms: the genuine aber- rant goiter, which has developed in embryonal remains of the gland; and false aberrant goiter, which develops in bits of gland secondarily and mechanically separated from the thyroid. The genuine form only need concern us. You will find the tumors in the median line always — an important diagnostic point. They lie above or below the hyoid, at the base of the tongue (lingual goiter), and much more rarely low down in the neck or behind the sternum. The treatment of aberrant goiter depends much upon the condition of the thyroid gland itself. If the thyroid be absent or its function impaired, one may succeed in curing the aberrant goiter by internal treatment; but if the thyroid gland be functionally intact, the aberrant goiter had best be excised. Diseases of the parathyroids are engaging the attention of clinicians and pathologists at this writing, and a few cases of parathy- roid tumors successfully removed have been reported. Inflammations of the thyroid gland are rare as compared with thyroid tumors, and inflammation of a goiter apparently i& less common than is inflammation of the normal gland. We need not concern our- selves extensively with this subject further than to observe that inflam- mations are acute and chronic; that when acute, they give rise to the familiar symptoms of pain, heat, redness, and swelling; and when chronic, show slight enlargements of the gland with a proliferation of connective 612 THE FACE AND NECK tissue, or present evidences of specific infection or of tuberculosis. The practitioner treats these inflammations on fjeneral jHinciples — with applications, Bier cupping, opsonic vaccines, potassium iodic!, and incisions. In leaving the subject of disease of the thyroid gland one reflects that the topic is not yet complete, as are, for example, appendicitis and disease of the bile-passages, though one feels more and moi'c strongly, as evidence accumulates, that all thyroid disease is coming within the surgeon's province — especially nodular goiter and Graves' disease. For this reason surgeons protest, as they have long protested in the case of appendicitis, that all diseases of these organs should be seen by a surgeon in consultation, for no man may say when or whether an operation may be necessary. Thyroid disease is a surgical disease. PART VI THE HEAD AND SPINE CHAPTER XXIII THE SCALP Surgery of the head and spine, by which one understands especially the surgery of the nervous system, is beginning to occupy a far more important place than was thought possible less than twenty years ago ; and those operators who have followed the course of the debate on the subject must have been impressed with a radical divergence of views in this field, associated always with a slow but steady progress, within the ken of the present surgical generation. In the later eighties, when opera- tions within the abdominal cavity were becoming frequent and the con- fidence of abdominal surgeons was estabUshed, we tried to believe that an equally brilliant future awaited cranial surgery. The belief was founded upon our recently acquired appreciation of aseptic surgery. Men began to say that it would be no very serious matter to open the dura, to handle the brain, to explore its depths, and to remove its tumors; while operations upon the spinal column would increase likewise in frequency. Fortunately or unfortunately, the results of endeavors in. neurologic surgery were not commensurate with the activity of enthu- siasts. The death-rate continued high, the expected relief from syinp- toms was not secured or was found to be temporary only, and a resulting skepticism gradually was created from which to-day only are we be- ginning to recover. The painstaking and informing investigations of Waldeyer, His, Victor Horsley, Harvey Gushing, Frazier, Spiller, Walton, Starr, and a few others, are convincing the profession that there is a hopeful future in this field, but that neurologic undertakings are far more difficult in the diagnosis, the inception, the performance, and the after-treatment, than are similar undertakings in the fiekl of abdomi- nal surgery. Each operation, when it deals with the brain or spmal cord, must be carefully planned and studied, approached with a wise precaution, and carried through timely, elaborately, accurately, and m-. telhgently. Already we see that the work on the nervous system by competent neurologic surgeons is far more effective than the often crude and hasty neurologic work of general surgeons; and so it becomes ap- parent that, for the present at least, and until neurologic surgery has been more highly developed, we must look to special experts for the best 613 614 THE HEAD AND SPINE results in the more obscure, difficult, and hazardous cases. Not that one would remove all head and nerve surgery from general surgeons — any well-ecjuipped surgeon should be competent to open the skull, to drain a cerebral abscess, to open the spinal canal, and to operate ujjon the peripheral nerves; but as yet the judicious observer cannot but feel that the great uncompleted work on brain tumors and other structures within the skull is still pioneer work, and should be delegated to specially trained surgeons so far as they may be found. A sei-ious obstacle hith- erto to the more rapid and intelligent progress of neurologic surgery is the common ignorance of neurologj- on the part of surgeons and the ig- norance of surgery on the part of neurologists. Our practice of referring neurologic cases to neurologists, in the first instance, who in their turn refer these cases to general surgeons for operation, must be deprecated. Our hope for the future lies in those surgeons who are versed in neurology — as yet a small and little appreciated band. Before advancing directly upon the great subject of brain and nerve surgery it is well to consider in somewhat conventional fashion the more frequent diseases and injuries of the scalp and of the bones of the head and spine. More than twenty-five 3-ears ago Frederick Treves published his useful little book on applied anatoni}', the first chapter of which deals with the scalp. So well did he exhaust the subject that nothing of material intei'cst has been added to it since his first publication. The reader will remember that — The scalp, or soft parts covering the vault of the skull, may be divided into five layers (the skin, the subcutaneous fatty tissue, the occipitofrontalis muscle and its aponeurosis, the subaponeurotic con- nective tissue, and the pericranium), and these five layers have their important influence in limiting or directing injuries and infections of the head. One perceives, therefore, that the skull has little external pro- tection from violence, the onty buffers of account being the thick tem- poral muscles on the sides of the head, the heavy occipital muscles behind, and the bones of the face in front. As Fowler observes, how- ever, the elasticity of the cranial vault is such that, on account of its peculiar conformation, it may return to its normal shape after a severe blow, so that a contusion only of the soft parts may result. CONTUSIONS OF THE SCALP Contusions of the scalp are of importance only as they confuse diag- nosis. A contusion is associated with extravasation of blood, and this extravasated blood in the scalp is so often sharph- limited by dense aponeurosis or pericranium as to give to the examiner the impression of the sharp bony edge of a fractured skull. If the surgeon is satisfied, however, that the lesion is a contusion onlv, he need fear no ill results, and may treat the disturbance by ordering rest and cold aj^plications. It is not too early in this discussion, however, to remind the reader that all injuries to the head should be regarded seriously and that the patient should remain quietly under observation for two or three days at least. CONTUSIONS OF THE SCALP 615 It is our hubit at the Massachusetts General Hospital, in the case of a head injury in which there is the slightest doubt of diagnosis, to keep the patient in the ward until all suspicion of possible deep-seated damage is banished. Hematoma of the scalp differs in degree only from simple contusion. If considerable veins or small arteries are torn, an abundant escape of blood may occur beneath the aponeurosis or skin. This may give rise to an extensive tumor covering half the head possibly. The blood- clot may become infected, with a resulting abscess formation. In any case if the clot does not disappear within a few days, the surgeon is justi- fied in opening freely through the scalp, washing out thoroughly the blood and detritus, and closing the wound after providing for drainage. In each case in which such incisions are necessary the patient's head should be shaved over the area corresponding to the lesion. Wounds of the scalp heal rapidly, for the scalp is intensely vascular. The drain should be removed on the second day, and one should expect to find the line of incision closed firmlj^ by the fifth day, when the stitches may be removed. A thick, elastic, gauze and cotton dressing, held in place by a head bandage, should be applied to these wounds, in order to absorb the discharges, and for the protection and comfort of the patient. Never use plasters. Scalp wounds are the most common of extracranial lesions, and every practitioner first and last sees hundreds of them. They are easily cared for, as a iiile. The familiar " broken head" of sporting parlance is a contused scalp wound commonly, and as the head is one of the most exposed parts of the body, it comes in for all sorts of violence. There is this interesting and rather peculiar fact about the effects of " cracks on the head " : a straight cleft or incised wound apparently may be caused by a blow from any kind of implement — a knife, saber, bludgeon, brickbat, parlor floor, or bed-post. The scalp is so tightly stretched over the cranium that a sharp blow with the bluntest instru- ment causes the skin to tear in a fairly straight line, so that the appear- ance of an incised wound is produced, though about the wound there msij be any amount of tissue crushed and disfigured. If incised wounds are transverse to the anteroposterior line of the skull and penetrate to the bone, they gape. Longitudinal wounds do not gape. According to the nature of the wound, so shall you treat it. If it be incised, check the hemorrhage, clean the parts (after shaving the head about the lesion), and sew it up tightly. Incised scalp wounds heal promptly because the scalp's blood-supply is abundant. In two days you shaU find the union sound. If the wound be contused, especially if it be filled with dirt, it must not be closed tightly. Shave the surround- ing skin; cleanse thoroughly the damaged region; draw the edges of the wound together at two or three points with silkworm-gut stitches, leaving spaces for drainage, and apply a large absorbent dressing. In the case of such dirty wounds remove the dressings frequently and watch for eiysipelas or extensive sloughing, which must be treated with irrigations, removal of necrotic tissue, and fi-esh clean dressings two or 616 THE HKAD AXD STIXE three times a day. The uhiniate source of anxiet}' in these cases is a possible extension of the infection through the cliploe to the men- inges. A curiously striking, shocking, and disfiguring injury to the head is a complete scalping, — avulsion of the scalp, — an accident confined to women almost entirely, and to factory women, because the long hair of factory women becomes caught in machinery which tears the scalp from the head. The great raw wound which results, in its outline follows almost invariably the insertions of the occipitofrontalis muscle from eye- brows to occiput, and fi'oni ear to ear. The depth of the wound varies, depending upon the abundance and strength of the hair. The skin alone Fig. 401. — Avulsion of the sralp ('Massachusetts Gfucral Hospital). may be torn ofT, or all the soft parts maj' be involved down to and in- cluding the periosteum. As Fowler points out, since these accidents happen to anemic and poorly nourished women, as a rule, the surgeon should begin treatment as soon as granulations have begun to form. The only treatment of any service is Thiersch grafting, over which the attendant must labor faith- fully until grafts sufficient to cover the entire head have been taken. See to it that the grafts be not destroyed by needlessly tight bandaging. TUMORS OF THE SCALP Tumors of the scalp are extremely common — especially benign tumors; and of these, wens are far the most frecjuent. Wens arc known TUMORS OF THE SCALP 017 as sebaceous cysts. They appear to be epidermal inclusions, and grossly on dissection arc found as thin-skinned sacs filled with sebaceous matter. They are often multiple, develop in any part of the head, are movable under the skin when not inflamed, and arc easily removed. They are best taken out through a crescentic incision incirclmg the base. The suro-eon burrows under the wen through this incision, lifts up the growth with the flap, and dissects off the wen from the flap. By workmg m this fashion he will get out the whole of the sac, which is essential, for a portion of the sac left behind may give rise to a recurrent wen. Dermoid cysts of the scalp resemble wens, but they are less common, are congenital, and are usually found along the external portion of the supra-orbital arch and at the fontanels. The reasons for removing wens and other cysts are their increasing size and their absurd or offensive appearance. Fig. 402.— Neurofibroma of scalp (Valentine Mott's case). Helmholz and Gushing ^ describe an interesting case of neuro- fibroma ^ of the scalp (von Recklinghausen's disease), a rather rare con- dition giving rise to scalp tumors, with great relaxation of the scalp, some- times allowing marked drooping of the ears or showing as pendulous, down-hanging masses from various parts of the head. The_ cure con- sists obviously in a thorough removal of the tumors and excision of por- tions of the scalp. . , Other familiar but non-malignant tumors of the scalp are: cephal- hematoma, lipoma, horns, and meningocele, a consideration of the last of which falls properly under the subject of diseases of the menmges (Chapter XXIV). 1 H. F. Helmholz and Harvey Gushing, Elephantiasis Nervorum of the Scalp: f. Manifestation of von Recklinghausen's Disease, Amer. Jour. Med. bci,, beptember, ^^°^2-Molluscum fibrosum, see J. Bland-Sutton, Tumors Innocent and Benign, fourth ed., p. 145. 618 THE HEAD AND SPINE Malignant epithelial disease rarely attacks the scalp, and when it does so. is generally in the form of rodent ulcer, extending from the face, a description of which the reader will find in Chapter XX. Sarcoma is a rare disease of the scalp. It has been observed oc- casionally in the occipital region, but is so infrequent that it may be regarded as a curiosity almost. A characteristic phenomenon of the region of the scalp is aneurysm — generally the cirsoid or racemose variety. A simple aneurysm — a circumscribed dilatation of a portion of a single vessel — is very rare, but cirsoid aneurysm — a diffused dilatation of a number of connect- ing arteries — is not uncommon. This curious aneurysm, like varico- cele of the scrotum, has been compared to a bundle of worms. Its appearance is striking and generally unmistakable. The arteries are enlarged in both circumference and length, and are forced into an ex- tremely tortuous or serpentine course. One makes the diagnosis al- most instantly by sight, while the touch confirms the impression of the arterial character of the disease. Far more rare than cirsoid aneurysms are varices of the scalp, which somewhat resemble aneurysm, but are less tortuous, are softer, and are devoid of pulsation. The cure of cirsoid aneurysm is by no means easy, and various different attempts at a cure have been made, with more or less success. The best course probably is that proposed by Dieffenbach, namely, to excise at repeated operations portions of the scalp bearing the aneurysm, allowing the wound to heal each time before operating again. Another excellent plan, to be adopted when the aneurysm is not too large, is totally to excise the aneurysmal area, with the skin, and fill in the gap with skin-grafts. Whatever the method employed, the surgeon will find the undertaking to present a nice and somewhat puzzling problem. The practitioner will often encounter lesions and diseases of the scalp other than those I have enumerated here, but I have attempted in this chapter to discuss those problems only which are peculiar to the scalp itself. CHAPTER XXIV THE SKULL, BRAIN, AND MENINGES Ix this chapter ^ve shall consider an important group of subjects. and shall deal with regions and organs second in importance to none in the body. Many surgical writers have treated of the skull and brain as separate entities, and, anatomically, these structures are distinct ; but clinically, lesions of the brain and of its bony covering are so intimately associated that the surgeon must always think of them together. Their injuries and diseases often give rise to a symptom-complex, while opera- tions which deal with the one concern the other in great numbers of cases. Surgery of the head ranks with surgery of the long bones as the most ancient form of surgery in the history of our art. Trepanning was prac- tised in remote prehistoric times, as the skulls of Egyptians and Aztecs bear witness, while later Egj-ptian surgeons, followed by the Greeks and their disciples, the Romans, practised opening the skull, not only for the relief of fracture pressure, but for the cure of epilepsy ._ Throughout surgical histor}^ the records of our best observers abound in descriptions of head injuries, and of the symptoms and operations for their relief, so that at the beginning of our 0T\-n generation abundant material was in hand to aid us in such studies. Those former writings, however, were con- cerned alwavs with a factor which marks off ancient cranial surgery from our own. Sepsis and its results were ever-present complications. To- day, in considerable measure, we are not concerned with sepsis, except when treating fractures of the base of the skull. A cracked skull is a smaU matter in itself, for cracks in the bones of the head heal readily and intrinsically do no special harm. We dread a fractured skull for its complications and results; for the associated damage to the cranial contents. Every general surgeon must deal with head injums, though one mav question the capacity of every general surgeon to deal adequately with manv intracranial diseases. Let us consider broadly, therefore certain important general topics: fractures of the skuU— simple and compound, depressed and non-depressed, of the vertex and of the base; injuries to the brain— pressure, compression, hemorrhage, and other sig-ns of cerebral disorder; injuries to and inflammations of the^men- inges; inflammatoiw affections of the bones and tumors of the bones; hernia and fungus 'cerebri; abscess, tumors, and foreign bodies withm the skull; epilepsy, hydrocephalus, and the methods of demonstrating and treating these various profound lesions. 619 620 THE HEAD AND SPIXE FRACTURES OF THE SKULL We are taught that fractures of the skull group themselves nat- urally under four important headings — simple, compound, non-de- pressed, and depressed. From the earliest times a simple fracture of the skull has been taken to be a relatively trifling affair. It was for- merly said, and is still thought by many careless practitioners, that a clean crack through the skull, without injury to the skin or depression of the bone, does no special harm. In some cases such a crack may do no special harm, but so diverse ai-e conditions and so undetermined are the personal equations of patients that no man may say, at once or even after days and weeks, what will be the outcome of a skull fracture apparently simple and uncomplicated. The other day a man, two weeks convalescent from a crack on the head, was leaving the Massachusetts General Hospital to walk home. By chance he was met at the door of Fig. 403.— Skull indented without fracture (Ma.ssacliu.sells; General Hospital). the ward by the visiting surgeon, who noticed a suspicious uncertainty in the man's steps. The surgeon countermanded the order for discharge and sent the man back to bed. That night the patient lapsed into un- consciousness and was dead within a week. At the postmortem a large area within the skull was found to be occupied by blood-clot and dis- organized brain. The obvious skull damage was of no moment, but the concealed damage was fatal. Harvey Cushing gives us an interesting story of a young man who was tilted out of the back seat of a wagon and fell upon his occiput. His physician could find no evidence of external injury, and treated the case lightly as a probable simple fracture without depression; but undoubtedly there was consideiable local hemorrhage between the bone and dura. At any rate, after two months the patient became an epileptic, and finally a year later, when he was operated upon, the surgeon discovered an adherent dura and a depressed scar over Broca's convolution. An experience of such cases gives one pause, and FRACTURES OF THE SKULL G21 leads to the conviction that any persistent sj'mptoms of intracranial damage call for a trephining and exploration within the skull. Such considerations will suggest to the reader the extreme difficulty of making a prompt and exact diagnosis of head injuries, and will indi- cate also the uncertainty of the surgeon when he comes to their treat- ment. The unique conformation of the skull adds to the difficulty of diagnosis, for in the skull we have to deal with an outer table, a diploe (corresponding to the medullary cavity of long bones) , and an inner table. In the case of a simple fracture it may be possible to determine the extent of the injury by touch or by consideration of the immediate S3^mptoms. Moreover, in young children, after an injury, there may exist a depression of the skull, without fracture, corresponding to the so-called green-stick Fig. 404. — Incircling fracture of the skull (Keen's Surgery). fracture in the long bones. While a simple crack of the outer table is harmless enough, it is often impossible to say whether or not the inner table be damaged also, and we know that a trifling lesion of the outer table often is associated with an extensive lesion — splintering and depression — of the inner table. One must distinguish also the difference, often vital, between simple fracture of the vault and fracture of the base of the skull, bearing in mind always that the two maj^ be associated, on the one hand, as independent lesions, or, on the other, as a continuous lesion, in as much as a crack beginning in the base mary run around to the vault (fracture by exten- sion) partially or entirely incircling the skull. Conventional writings describe independent fractures of the vault and independent fractures of 622 THE HEAD AND SPINE the base, but clinicallj' one may not always draw such a distinction between these two fractures. Most fractures of the vault are due obviously to direct violence — to a bloAV or fall upon the head — and these causes of injuiy arc evident enough ; but one variety of fracture of the vault deserves special mention — the punctured fracture. Kecently I was asked by a physician to see a little boy whose history of injury ran somewhat as follows: Twenty-four hours before I saw him he was playing in a street trench which was being excavated for the laying of pipes. In the midst of his play he ran home with a thin stream of blood trickling through his hair, and told how a heavy, sharp-pointed spike had fallen upon the top of his head. The physician who was called thought little of the matter at first, but became alarmed after a few hours when the boy lapsed gradually into uncon- sciousness. I opened the skull and showed the condition to be one of punctured fracture of the inner table, with laceration of the meninges and brain, and extensive intracranial hemorrhage with meningitis. The cause oi fracture of the base of the skull is not always so obvious. Commonly, basal fractures are independent of fractures of the vault. We used to hear of fracture by contrecouj), and of fractures due to a com- pression and bursting force, but these explanations of basal damage and fracture no longer are held tenable, and physicists have come to accept Aran's theory of irradiation, j^erhaps with modifications, as ex- plaining fracture opposite to the side on which the blow fell. Cer- tain it is that in many cases force exerted upon one side of the head demonstrates itself by a lesion on the opposite side — at the base or else- where. However, direct violence is by far the most common cause of basal fracture — direct violence Q,pplied either from above or below. A crushing force descending from above maj' crowd the base down upon the spinal column; or a man falling from a height and landing on his feet may have his skull driven down and crushed at the base, in the same manner as when a carpenter forces down the head of his hammer by strik- ing its handle upon the bench. A fracture of the base is more apt to be compound than simple.\ A glance at a skull will remind the reader that its base is divided intoJhree.fosssD — the anterior fossa, marked by the Jesser wing of the sphenoid ; the middle fossa, bounded by the lesser wing of the sphenoid in front and the petrous bone feeliiiid; and thejioatcriox fossa, extending from the petrous bone to the Jateral sinus behind, and containing the whole of the foramen magnum and basillar process. From this arrangement of parts the student will perceive that simple fracture of the base of the skull occurs in the posterior fossa only. Fracture of the anterior fossa becomes at once compound through open- ing into the sphenoid sinuses or upper nasal passages, so that blood and cerebrospinal fluid escape through the nasfii Fracture of the middle fossa nearly always involves the petrous bone, and so becomes compound by communication with the outer air through the jxtemjj auditor}'- canal, by which blood and cerebrospinal fluid escape; but fracture of the post- erior fossa, unle^the basilar process be broken and the pharynx be FRACTURES OF THE SKULL 623 opened, remains simple, so that extravasatcd blood shows itself late, under the skin only, below thejiLaaJLoiLLprocess. Coticpound fracture of the vault differs from simple fracture of the vault in no material fashion, so far as anatomic changes are concerned, except that in compound fractures the damaged bone and deeper parts are exposed to the air through the rending of the soft pai-ts, so that there results often septic infection of the brain and its coverings. The characteristics of skull fractures vary. There may be a simple crack of the outer table or of both tables; there may be splintering of the bone into sundry fragments ; and there may be depression of the broken bone, fragments being driven in and made to impinge upon the meninges and brain. The meninges may be torn, the brain may be lacerated, arte- ries and veins may be divided, hemorrhage may take place within the skull where the blood may lie compressing the brain, or the blood may make its way outward; while an extensive edema of the brain itself — the result of its rough treatment — may become established. With this understanding of the appearance of fractures of the skull — of the vault and of the base, simple and compound — let us now consider the vital consequences wdiich may follow these head injuries; bearing in mind always that whereas the symptoms due to simple fracture are dependent on pressure and possible laceration, in compound fracture, on the other hand, there are added often to these symptoms the grave evidences of sepsis. The symptoms and signs of simple fracture of the vault are elu- sive. It is by no means easy, always and at once, to determine the pres- ence of a vault fracture, because bruising and swelling of the soft parts may so mask the damage to the bone that one cannot accurately feel the fracture. In such case the surgeon may conclude that he had best wait for subsidence of the swelling or the development of later symptoms before making his diagnosis. The a:-ray may decide the question. On the other hand, extensive fracture with marked depression of the bone may be instantly obvious. Should the patient's condition be at all serious — that is to say, should there be present unconsciousness or other evidences of cerebral disturbance — the surgeon had best turn back a flap of soft parts so as to determine the condition of the skull. Compound fracture, on the other hand, can be made out easily, for through the rent in the soft parts, enlarged, if necessary, the surgeon may introduce his gloved finger and feel the broken bone, taking pains alw^ays not to mistake normal suture lines and Wormian bones for a fracture. Beyond the signs demonstrated through digital exploration there are sundiy other evidences which may lead one to the conclusion that serious internal damage exists, and we shall now consider some of the classic symptoms of head injury. Concussion of the brain may or may not be associated with frac- ture. Doubtless concussion is in itself a genuine entity, which alone may cause death, or, when associated with obvious brain lesions, may be a contributory cause of death. Since 1677, when Borel first described 624 THE HEAD AND SPINE concussion, the word has been familiar to surgeons, though their defi- nition of concussion frequcntl}' has changed. \\'e regard concussion us a positive condition, not anatomically demonstrable, not to be con- fused with contusion, compression, and laceration. A concussion of the brain results from a heavy blow or a series of light blows on the skull, and the experiments of Kocher, as explained further by Tilhnan, enable us to formulate the hypothesis that the violence inflicted upon the skull is transmitted to the brain, which, inclosed in its air-tight cap- ' sule of bone, is set in motion by the force of the blow. Since the white brain substance is of a higher specific gravity than the gray, it continues in motion for a longer time than the gray, with a h3pothetic resulting distortion along the boundary between gray and white matter, which causes the loss of consciousness.^ This explanation of concussion sug- gests that the distinction between concussion and contusion is one of degree only — indeed, Kocher assumes that concussion is a form of con- tusion, and proposes to drop the word concussion from surgical literature. However, since a contusion is commonly associated with actual and obvious anatomic changes, and since concussion is not, it seems well to the writer to retain the old word. Concussion gives us a distinct chnical picture. The patient is im- coDscious; he appears to sleep; he breathes rapidly or irregularh* ; his pulse becomes slow, sinking to 40 or even less, but if the patient dies at this stage, the pulse rises and flickers toward the end. If he recovers, it rises slowly and strongly. In slight degrees of concussion the un- consciousness may be less marked, or so transient as to escape obser- vation. There exist pallor and vomiting also, but the vomiting occurs once only, as a rule. There are often profound vasomotor distui-bances. The reaction comes gradually ; early or late, when consciousness returns, the face becomes reddened and the pulse grows full and strong. This stage of reaction is sometimes followed bj' glycosuria, poljairia, and albuminuria. A favorite old examination question for medical students is — dis- tinguish between concussion and compression of the brain. Compression of the brain implies a distinct anatomic change within the skull — the presence of some unwonted substance pressing upon and crowding the brain from without. As Dennis has pointed out, one must not confuse the terms compression and pressure. Compression may be due to an effusion of fluid (blood or cerebrospinal fluid) beneath the skull, pressing upon the brain, a condition usually resulting from traumatism,, the rupture of a blood-vessel, or from depressed bone. Pressure (intracranial pressure) is due to a force acting from within the brain. For instance, a growing tumor, or the collection of fluid within the ventricles, may raise greatly the intracranial tension and so give rise to pressure symptoms. It must be obvious that the compression exerted by a mere depression of bony fragments is not likely to cause immediate and profound symptoms unless there be associated damage to the brain, with extensive escape of fluid, or cerebral edema. The ^ Von Bergmann, System of Surgerj^, American edition, vol. i, p. 186. FRACTURES OF THE SKULL 625 symptoms which occur in compression are probably clue to the flowing out of cerebrospinal lluid from the meningeal spaces into the general ventricular cavity, into the spinal meninges, and by the opening of the inferior boundary of the fourth ventricle. Aon Bergmann pointed out that, by the removal of this fluid support from the brain in the area where the large vessels enter, direct sj'stoUc impressions are conveyed to the cerebral mass. We have seen how the acute cerebral disturbances of concussion are clue to mechanical violence, apparently affecting the brain in all its parts. In compression, on the other hand, the cerebral disturbances are not due directly to the traumatism, but to a secondary- slowing of the circulation. In other words, the symptoms of com- pression of the brain are the result of a retarded circulation of fresh oxy- genated blood. Cerebral anemia results. This slowing of the circula- tion, associated with the faU in the pulse, checks the activity of the cen- tral nervous svstem. There result certain characteristic symptoms, and these sympt'oms are to be divided clinically into two stages: the stage^ of stimulation and the stage of parahjsis. That first stage of stimulation appears to be due to (Kocher) a compensatory rise of blood-pressure, which foUows immediately upon the early increase of intracranial ten- sion. In that stage the patient complains of headache, and he vomits; he is restless, delirious, with a flushed face and contracted pupils, while at the same time the observer finds with the ophthalmoscope choked disk: and the Riva Rocci apparatus shows a constant rise of blood-pres- Fure." while the pulse slows. AfterT\-ard there comes the stage of paraly- sis. Increasing pressure within the skuU causes increasmg cerebral anemia ; stupor and unconsciousness deepen into coma. The respiration becomes stertorous and of the Cheyne-Stokes type; the pulse becomes rapid and soft : feces and urine are passed involuntarily, the breathmg becomes more or less irregiilar until it ceases, the heart beating for several minutes after the respiration has stopped, until death ensues. It is worth our while briefly to consider in some detail these various s^Tnptoms. The headache h instantly present, growing more mtense, alwavs persistent, rarelv localized, and is easily aggravated by motion or by external pressure. The vomiting is sudden, spontaneous, and not preceded bv nausea. It is more persistent than the single act of vomit- ing seen in cases of concussion. Headache, vomiting, and blindness compose the trioloov indicative of serious intracranial disturbance of whatever origin, and we have seen that the choked disk leading to blind- ness frequently results from traumatic compression. In the early stage of compression the patient is constantly restless, rolling his head, groan- ing, and tossing his body. As the stage of paralysis suiperxenes the pulse, hitherto slow.'^becomes rapid— a most unfavorable sign, indicating an approaching paralvsis of the vagus. In the stage of stimulation the pupils are contracted, but later, with coma, the pupils become widely dilated, as a mle: though rarely, and as a result of some special localirn- tation, thev mav varv.mav contract and respond slowly, if at all. to hght. Note the condition of the'conjunctival reflex: if that is gone, the pupils will not react to light. The condition of the pupils, as I have described 40 02G THK HKAD AND SPINE it, applies especially to cases of general intracranial pressure, but a further anil confusing situation arises when conijjression is exertetl u))on a portion of one cerebral hemisphere only. In such a case the pupil on the affected side is wont to be dilated and motionless even. Choked disk begins early, and continues to the end if the patient does not recover, and choked disk, if present while the patient is unconscious, and if long enough continued, leads to blindness. Unco7tsciousncss may come on suddenly or gradually and may be partial or complete. Sudden uncon- sciousness is due to concussion or to apoplexy. A slowly increasing hemorrhage causes gradual unconsciousness. Stupor does not signify complete unconsciousness, for the patient in stupor may be roused to recognize his surroundings. Profound coma implies complete uncon- sciousness, the impossibility of being roused, abolition of the reflexes (which may have been active in the earl}' stages of compression), flaccid muscles, incontinence of feces, and incontinence or retention of urine. The temperature is significant. For a short time after a head injury the temperature is alwaj'S subnormal, indicating a condition of pronounced shock in which the patient may die. If the patient reacts from shock, the temperature rises, ascending many degress — up to 105°, 106°, or 107 ° F. This steady rise is a grievous sign. In other cases the tempera- ture reaches a moderate height and there remains, marking time for a while. Its subsidence is a favorable sign; its subsequent rise, a fatal sign. These variations of the temperature — subnormal, high, and stead- il}' rising, and moderate without variation— are important prognostic signs. The nervous phenomena are extremel}- interesting in cases of pressure and compression. If the compression be sudden and excessive, there results always coma without voluntary movement. General paralyses or paralysis of one side only (hemiplegia) may be present and depend upon the site and extent of the head injury. A general and ex- cessive compression of the brain or the intrusion of a foreign mass, such as a blood-clot, between the brain and the bone at the base accounts for the symptoms of general paralysis. The presence of a foreign mass at one point, either over the vertex or at the base, without excessive general compression, gives rise to special localized nervous phenomena, such as accentuated reflexes at first from overstimulation, followed later by local paralysis as the pressure increases or is prolonged.' The course of the symptoms depends upon their cause, and whether the pressure be exerted continuously, or be modified or relieved. One perceives, therefore, that continued bone depression produces per- manent and constant encroachment on the cavity of the skull; extra- vasated blood may increase in volume so as to destroy life by compres- sion, or the hemorrhage may be checked, or the blood may escape out- ward; an abscess rapidly forming progresses continuously and causes con- stantly increasing pressure. The surgeon, therefore, must watch care- fully the symptoms to determine whether pressure is increasing, is stationary, or is diminishing. Lapse of time after the beginning of pressure S3'mptoms is another important factor in the problem. A high 1 L. B. Rawling, Lancet, April 9, 16, 23, 1904. FRACTl RES OF THE SKULL 627 degree of pressure, lasting for a short time and then relieved, may not kill the patient, while a persistently moderate pressure eventually may destroy the individual, and one must remember that persistent pressure leads to increasing cerebral edema and a consequent further increase of tension. There is one common and most serious cause of compression which demands some further consideration: Hemorrhage. — Let the reader remember that intracranial hemor- rhage ma}' be either traumatic or spontaneous. The vast majoiity of spontaneous hemorrhages come from the lenticulostriate artery and cause apoplexy, a disease within the province of the physician, in most cases. We have to consider here traumatic hemorrhage, in which- the commonest source of bleeding is one of the branches of the middle meningeal arter}-. An uncommon source of bleeding is a torn sinus, or there may be a rupture of one of the small vessels in the pia. The middle meningeal artery is a branch of the internal maxillary, in its turn one of the main divisions of the external carotid. The middle meningeal enters the skull through the foramen spinosum, divides into three branches, ^^fe ^ \ '«f-?' Fig. 405. — Fracture of the inner table with outer table intact (Campbell) . Fig. -106. — Fracture of the outer table with the inner table intact (Campbell) . and passes up on the inner surface of the cranium, which it furrows deeply, lying outside of the dura. This extradural position of the middle meningeal is important and significant in the case of head injuries, for damage of the middle meningeal causes extradural hemorrhage. Now there are three forms of traumatic intracranial hemorrhage: (1) Extra- dural; (2) subdural (between the dura and the brain), and (3) cerebral (within the brain substance). Extradural hemorrhage is probably the most common form seen in accident surgery, and the fashion in which the patient was hurt seems to have little bearing on the production of hem- orrhage. Splintering and depression of the bone are not necessary. A short^ time ago I saw in the accident room of the Massachusetts Gen- eral Hospital a boy of ten who had been struck above the left ear by a carriage-pole some two hours before he was brought to the hospital. He had been knocked down and dazed, had risen, vomited, and staggered (concussion) ; he had walked home, where, as his mother told me, he suffered from twitching of the left arm and became stupid. He was brought into the hospital. When I saw him he was in a state of increas- ing stupor, as the house surgeon testified ; his left arm and leg were in a 628 THE HEAD AND SPINE state of paresis; both pupils were contracted and failed to react; the pulse was slow and hard, with tension of ISO, and tiie whole condition was obviously one of increasing cerebral compression from hemorrhage. There was a slight bruise over the left ear, but no palpable evidence of fracture there. The reader \\ill observe that the kjcal symptoms of paresis were on the left side, indicating a cortical brain disturbance on the right side. I relate these facts in order to show how a severe and alarming lesion — a rupture of the middle meningeal artery — may arise without direct violence to the affected artery. In this boy's ca.se the damage was by cont ccoup, as we still say. The blow upon the left side of the head had ruptured a blood-vessel on the right side. The subsequent conduct of the case was obvious, and the course satisfactory. The skull was opened over the anterior branch of the right meningeal artery; the torn vessel was found and tied; an extensive extradural blood-clot was washed out; the patient's symptoms improved instantly, and eventually he recovered. This story demonstrates a possible but somewhat infre^iuent cause of meningeal hemorrhage — indirect violence. Fig. 407. — Both tables fractun-d and de- pressed (Campbell). Fig. 408.- — Compression of the brain caused by collection of blood or pus between tlie bone and the dura mater (Campbell). A far more common cause is direct violence, with crushing of the skull over the vessels, and a tearing of the artery by splinters of bone. In either case unconsciousness may be delaA'ed, so that stupor and coma are late symptoms, provided the initial violence has caused no marked concussion. With the enlargement of the clot toward the base the pupil on the same side ceases to react to light, becomes motionless, and di- lates widely, while if the clot be on the left side, aphasia occurs. Then, with the continued bleeding, other cortical centers are involved. The face becomes paralyzed, and there follows parah^sis of the arai, and finally of the leg, as the blood-clot extends up over the vertex. Con- vulsions are rare; the pulse becomes slow, sti'ong. and full: the breathing labored and irregular, while the temperature falls at first and then rises, as I have already described it. Should the fracture be compound, blood and lacerated brain may be forced out of the Avound, provided there be tearing of the dui'a. Subdural hemorrhage is commonly due to depressed fracture, as I have said — to depressed fracture with a tearing of blood-vessels. It is FRACTURES OF THE SKULL 029 not always possible to distinguish subdural from extradural hemorrhage, for the symptoms of the two are usually identical. Commonly, how- ever, subdural hemorrhage is associated with most active symptoms, with early coma and rapid fall in the temperature. An extremely important diagnostic measure is lumbar puncture, b}' which blood- stained cerebrospinal fluid is drawn. Cerebral hemorrhage presents symptoms identical with those of apoplexy, and the treatment of the two conditions is the same, except that it is permissible, though hazaixlous in the case of cerebral hemor- rhage from trauma, to ligate the common carotid artery on the side af- fected. Compound fracture of the skull sometimes causes the iTipture of a venous sinus, and occasionally sinuses have been w-oundecl in the course of an operation. Obviously, the symptoms of hemorrhage from such a wounded sinus are quite similar to the already described symptoms of arterial hemorrhage, except that venous hemorrhage is slow and is controlled easily by pressure. Harvey Cushing, writing in 1902, 1903, and 1905, demonstrated, in papers of remarkable interest, the possibility, if not the vital importance, of operating for the intracranial hemorrhage of the neic-born } All physicians know the sad results of these hemorrhages in babies — results which have been grouped under the common term " birth palsy." These infants do not always die at once — indeed, they may live to grow up and attain to old age even. The immediate effects of these birth hemorrhages are seen in convidsions, followed by paralyses of one or both sides; by loss of vigor; by gastro-intestinal disturbances, stupor, coma, and death. Or if the hemorrhage be sHght and confined to one side only, there may result corresponding paralyses of the leg, the arm, and the face, and the patient will survive to reach maturity in this crippled condition. Some of the victims become epileptics. Some are idiots. Cushing vigorously maintains the thesis that many of these infants may be saved with functions unimpaired; and his experience in a number of cases bears out his contention. The hemorrhage is usually venous, and is due to rupture of some of the delicate and poorly supported venous radicles of the cerebral cortex. The cause of the inipture is some birth violence— the application of forceps, the undue overlapping of the cranial bones, or possibly asphyxia of the baby. Cortical hemorrhage is a common cause of infant mortal- ity in those babies which die soon after birth, for the collections of blood may be as large as a cerebral hemisphere, and may penetrate into the cerebellar fossa even. These cases are grave, urgent, little understood. Many of them can be made mild and simple, and should be recognized at once. A com- petent surgeon should be called to open the skull through a bone-flap, wash out the clot, restore the dura, and replace the severed outer parts. Contusions of the brain comprise another variety of injuries asso- iThe Mutter Lecture for 1901, Amer. Jour. Med. Sci., September, 1902; ibid., June, 1903; ibid., October, 1905. 030 THE HEAD AXI) srixE ciatcd often with the conclitions we have (liscu.s.scd — fracture, concussion, pressure, heniojTliage. Contusions of the brain are conditions al)out which generations of surgeons have wrangled, confounding and identi- fying contusion with concussion. I have exphiined how such eminent authorities as Keen and Kochei' regard concussion as a mild grade of contusion. In this writing I follow the teaching of von Bergmann, who limits the term contusion to those brain injuries which aic actually associated with gross anatomic damage to the tissue. V\v distinguish also between contusions and vounds of the brain. A blow upon the skull which damages th(? underlying brain without exposing it to the outer air, whether the skull be fractvired or not, produces a contusion of the brain. A blow upon the skull which damages the underlying brain di- rectly by fracture and exposes it to the outer air results in a wound of the brain. Contused brain ma}^ vary in extent from a trifling point to an area as large as a whole cerebral hemisphere. Contused brain is a mass of blood, cerebrospinal fluid, and disorganized, crushed brain tissue. Contusions of the brain may be multiple or single, while the results and subsequent course of the contusion vary remarkably. Since there is no avenue for the advent of infecting organisms, sepsis does not follow contusions. At first there may be many of the symptoms characteristic of concussion and pressure. There may be unconsciousness, coma, vomiting, slowing of the pulse, a fall of the temperature, stertor, parah'- ses, choked disk, and the other familiar symptoms. If recovery ensues, the symptoms may disappear wholly or in part, but usually certain stigmata remain or develop, such as blindness, paralyses, epilepsy, or insanit}' ; and these stigmata are due to the curious partial or ineffective healing of the damaged brain, which goes through a routine of recon- structive changes: blood and brain tissue are dissolved and absorbed, so that at the site of the contusion there results a cleft or cavity which becomes filled gradually and transformed into a scar, w^hile sometimes a so-called cyst persists. Certain it is that extensive traumatic defects of the brain are not closed by a regeneration of brain tissue. Moreover, one sees occasionally cases in which, during the course of years, a degen- eration of the nervous elements takes place, proceeding far bej^ond the limits of the original injury — yellow softening.^ Such in brief are the characteristics, conditions, and results of cerebral contusion, and one feels often that immediate death would be the happiest lot for the unfortunate patient. Wounds of the brain take on many of the characteristics of con- tusions, but in the case of a wound, sepsis fi-equently lends additional gravity to the disaster. Writers commonly divide wounds of the brain into three classes — punctured, contused, and lacerated. Such an artificial division is by no means always obvious — especially the distinction between contused and lacerated wounds. Nor is the distinction vital. Suffice it for the practitioner to recognize a penetrating wound of the skidl with damage to brain tissue and the opening of an avenue for sepsis. The * R. U. Kronlein, in von Bergmann's System of Surgerj-, vol. i. FRACTURES OF THE SKULL 631 history of brain injuries abounds in curiosities and amenities. Surgical writers from the times of Pare and of Larrey to the most modern of the Japanese tell numerous stories of the destruction and loss of brain tissue; of projectiles traversing the brain, and of foreign substances lodged in the brain, without subsequent notable results. These occur- rences are in striking contrast to the deaths following slight blows on the head — deaths due to the tearing of vessels, with subsequent hemor- rhage and com})ression. Punctured wounds of the brain are among the most curious of all the curiosities in our records, and none is more Fig 409. — The Harvard " cro^v-bar case," with subsketch showing relative size of skull and crow-bar. interesting than the famous "crow-bar" case of the Harvard Medical School— a case in which a quarrj-man's tamping iron entered from below the anterior fossa of his skull, passed out through the vertex, and left the man not much the worse for his surprising adventure. Years afterward when he died both the skull and tamping iron were recovered, and now repose together in the Warren Museum at Harvard. It is needless in this place to rehearse the signs and symptoms associated with wounds of the brain. Those signs and symptoms are quite similar to the evidence of brain injury which I have already described — though one must constantly bear in mind the dangers of 632 THK HKAI) AND SI'IXE sep^iis in the case of ])iaiii ^v()Ululs, and the fre^juent Lite evidences of sepsis. There are three forms of sei)sis, to be studietl further and later. Suffice it here to note the three: meningitis, cei'ebral abscess, sinus thrombosis; and to observe that, of the thi-ee, meningitis develops early — in from thirty -six to forty-eight hours after the injury; absc(\ss, early or late — as early as the fifth or sixth day, as late as the thiid or fourth year; while sinus thrombosis appears usually towai'd the end of the first week. Fig. 410. — Harvard " crow-bar case." Note wound tliiough aiitnior fossa on left. Patient lived many years after the accident. In speaking of concussion and compression a few pages back I referred to the favorite old examination question^ — the distinction between concussion and compression. We are now ready briefly to sum up that distinction : In Concussion. !. The symptoms appear immediately after tlie accident. Unconsciousness and vomiting. No localizing symptoms. The pulse is slow without increase of ten- sion. The respiration is slow. The temperature changes little. I Tiie ])upils may Ite dilated or con- tracted. Lumbar puncture draws a negative fluid. In Compression. The symptoms are usually delayed, and appear after a free inter^•al. Restlessness, stupor merging into coma. Convulsions or paralyses indicating local cereiiral damage. The j)ulse is slow and of high tension. The res])iration may he stertorous or of the Clu'yne-Stokes type. The tem))erature falls at first and then rises. The pupils are usually unequal — di- lated on the side of injmy and with a choked disk. Lumbar })uncture frequently draws a bloody fluid. FRACTURES OF THE SKULL 633 The reader will assume that, as a rule, a concussion is an affair less serious than is the condition of compression, ])ut the outcome of the cases does not always follow this assumption. Severe cases of con- cussion may end in sudden death, while cases of compression may be relieyed spontaneously or by a surgical operation, and the patient may recover perfect health. We have now considered in somewhat brief fashion certain fractures of the skull, with their complications and results — concussion, hemor- rhage, compression, and contusions and wounds of the brain. These complications and results are commonly associated with all the various forms of skull fracture. Before continuing this discussion further, we should examine in somewhat greater detail the subject of fracture of the base. Fracture of the Base. — All experienced persons are familiar with the fact that basal fractures are more serious than vault fractures. A few years ago students were taught that nearly all basal fractures are fatal, so that when the diagnosis of basal fracture was followed by recov- ery of the patient, the latter fact was regarded as good presumptive evi- dence that the base had not been fractured. We know now, however, that fracture of the base is followed by recoveiy in a great many cases, though it is still ipso facto a more grave injury than vault fracture. Why is basal fracture so serious? At the base are grouped the more important vital centers; an overw^helmingly large proportion of basal fractures are compound fractures; operations for the relief of basal damage are difficult or are ineffective. The extent of a basal fracture can never be determined accurately. All three fossae may be involved, or two or one. We often find at post- mortem a fracture of the posterior fossa which had been overlooked entirely, for fractures of the posterior fossa often give no definite charac- teristic symptoms. Moreover, there are dangers peculiar to each fossa: fracture of the anterior fossa promotes septic meningitis through infection from the nose and ethmoid cells. In fracture of the middle fossa infection advances from the nasopharj-nx and from the ear. Furthermore, injury to the middle fossa may involve the middle meningeal artery or the internal carotid; injury to the posterior fossa is seldoni com- plicated by sepsis, but may result in extensive tearing of venous sinuses, with a consequent hemorrhage and pressure. One sees that fractures of the middle fossa appear at first as the most dangerous, though severe injuries to the brain are possible in fractures of all fossae;^ yet since the more important brain centers He in the posterior fossa, it is probably fair to estimate that the gravity of the prognosis in basal fractures increases in accordance with the position of the fracture from before backward. In general terms, the mortality of fractures of the base is about 65 per cent., while the mortality of fractures of the vault is about 23 per cent. Before entering upon a further consideration of head lesions — 034 THE UKM) AND SPIXE sepsis, tumor, and chronic infections especially — let us at this point sum up and fornudate the symptoms and diagnosis. The Symptoms and Diagnosis of Organic Head Lesions. — ilie reader should recall again a fact, which cannot be too often repeated, that a striking and notable distinction between intracranial lesions and lesions within the other important cavities of the body, lies in the fact that the organs within the skull are packed into a firm, immovable case, the organs themselves being non-collapsible. It is for this reason that an addition to the cranial. contents" or increase of the intracranial tension is associated with the most alarming and fatal results even. One of the most common and most significant of the symptoms of brain damage is unconsciousness, but there are manifold reasons for unconsciousness, so that it is worth our while in a brief paragraph to consider the causes. The Causes of Conm. — Coma is due to — (1) Brain injury; (2) apoplexy; (3) uremia; (4) epilepsy; (5) hysteria; (6) diabetes; (7) opium poisoning; (8) intoxication from alcohol, ether, and other anes- thetic drugs. It is by no means always easy to determine the cause of unconsciousness if the surgeon is unfamiliar with his patient's previous condition. In police station and hospital practice especiall}' puzzling cases arise, which often contain all the elements necessary for mortify- ing errors and for tragedy. When the attendant surgeon makes his examination, he should look with pains for evidences of injur}-, — damage to the scalp, the vault, and the base, — especially should he note bleeding from the ears or nose. But an epileptic, a (h-unkard, or a diabetic may fall unconscious and receive serious head injuries, and in such cases arise the puzzling problems. Search the patient for opium that he may be carrying; and note the odor of alcohol or opium on his breath. The victim of diabetes may smell of acetone (violets). Ex- amine the urine drawn by a catheter and observe in it the specific gravity, albumin, acetone, or sugar. Examine the fundus of the eye for choked disk. A lumbar puncture may draw- the bloody fluid due to subdural hemorrhage. Hysteric coma is most common in boys and young women, and the patient can swallow, though he cannot be roused. In postepileptic coma the state is one closely resembling sleep, and the patient can be aroused. In uremic coma one observes frequently localized edema, and there may be convulsions. In apoplexy there is often a subnormal temperature, and there may have been a single convulsion. In opium-poisoning look for the familiar pin-point pupil and a slow respiration, down to three or four a minute, i-emembering, at the same time, that hemorrhage into the pons will cause pin-point pupil, but paralysis as well, and a high temperature with sweating. Thus one sees that the problem which appeared so confusing at first may readily be resolved into elements more easy of explanation. Cerebral localization, next after questions relating to coma, furnishes us with information of great importance when we come to deal with the diagnosis of intracranial lesions, yet cerebral localization is a matter much misunderstood and much abused. Cerebral localiza- FRACTURES OF TIIF SKIM. 035 tion, first satisfactoiily demonstrated by Fritsch and Hitzig, is that science which shows tiie rehition of certain brain centers to special functions, voluntary acts and impressions, from which we deduce the conclusion that damage to, or destruction of, given brain centers will allect proportionately sensation and action. If this were all there is to it, cerebral localization would be a simple matter, and the exact site of brain lesions always could be determined, but, unfortunately, in the case of head injuries numerous factors complicate the problem; there may be multiple injuries; there may be damage by contrecoup; there nuiy be secondary hemorrhage and late inflammation, or secondary destruction of brain tissue. Moreover, the immediate symptoms may seem to give an exaggerated picture of the damage, while, on the other hand, extensive laceration of the brain may appear to be accompanied by slight and disproportionate symptoms, as the damage may have been inflicted upon a so-called silent area. Some years ago I saw in the accident room of the Massachusetts General Hospital a young man of \'igorous appearance, who seemed perfectly well except that five hours previously he had been rendered totally blind by a gunshot wound in the back of his head.^ He had been completely conscious since the accident; there were no paralyses, and all his reflexes were normal; the pulse was not slow. His only symptom was total blindness. The reader will see from Fig. 412 that the sight center of the brain is low dowTi in the posterior region of either hemisphere. This patient had been shot with a 32- caliber rifle through the right side of the occiput. The puzzling question was, why should he be blind in both eyes — but an examination of the wound quickly solved the apparent mystery. The bullet had entered the right side, had destroj-ed the right visual center, and, passing through the falx, had lodged in the left visual center, which it seemed to have destroyed likewise. An extremely interesting surgical fact is that a bullet fired from a rifle should have done so little damage after entering the brain. I enlarged thoroughly the wound in the bone, drained both hemispheres, and the man recovered eventually, with a useful, though limited, field of vision. The application of the case to our text lies in the fact that a gimshot wound in so vital a region as the occiput was shown, by the objective symptoms, to limit its damage to a surprisingly small area of brain. We see, therefore, the value of cerebral localization in one case, so far as a determination of the limits of brain damage are concerned. Not many years ago Chipault published a great and exhaustive treatise on the subject of craniocerebral topography, and the purpose of his book was to enable the surgeon to cut do"v\Ti directly through the outside of the head upon any desired area. By the aid of careful measurements from such fixed points as the external auditory canal and the occipital protuberance we were shovsTi how to find on the skull a point corre- sponding to that area of the brain, let us say, w^hich controlled the ^ Henry C. Baldwin, Gunshot Wound Involving Both Occipital Lobes, Boston Med. and Surg. Jour., February 15, 1906. 636 FKACTIHE.S OF THE SKULL 63- movements of the right hand. This is interesting, but less important than at hrst it was thought to be, for skulls vary so nuich that rules cannot be made to apply to them all. Moreover, in these days we are accustomed to explore the brain through large windows in the skull, and to reach any given point by observing its relation to certain fixed and well-knoAvn fissures and sulci in the brain itself. The student should be familiar, however, with the recognized landmarks described by Broca: The pteriou is a point on the side of the skull, 1\ inches posterior to the external angular process, on a level with the roof of the orbit. At the pterion the middle meningeal artery is found passing upward. The inion is a point marked by the external occipital protuberance. Fig. 414. — Diagram showing the various landmarks utilized as points of measure- ment in craniocerebral topography. Also, in red, main cerebral fissures and lobes of the exposed hemisphere (.Cushing in Keen's Surgery). The glabella is the midpoint of the smooth swelling between the eye- brows. The bregma, placed at about the junction of the sagittal and coronal sutures, is a point determined b}' the intersection of two lines —(1) the line connecting the two external auditory meatuses, and (2) the line connecting the inion and the glabella. Figs. 411, 412, and 413. — Diagrams illustrating the more definitely locafized of the cortical centers of the exposed part of the hemisphere, in relation to the main fissures and convolutions; also the '' word centers'' isensors' and motor) involved in the special mechanism for speech. (Receiving sensor^' stations in blue; discharging motor stations in red.) Drawn by accurate orthogonal projection of actual dissection. Note that centers for lower extremity are practically invisible from side, and that the best view of the motor field is obtained from above (Cushing in Keen's Surge rj-)- 038 THK HEAD AND SPINE To find the fissure of Sylvius: draw a line from the external angular process to the occipital protuberance. The fissure of Sylvius begins on this line, 1^ inches behind the angular process, the main branch running toward the parietal eminence, the ascending branch lying beneath the squamosphenoidal suture. The fissure of Rolando is the center of a most impoi'tant area, and marks the posterior limit of the motor region of the brain. It begins near the median line, one-half inch posterior to the middle of the dis- tance between the inion and the glabella. The fissure runs downward and fonvard at an angle of 67.5 degrees for a distance of 3| inches. Chiene's method for finding the fissure of Rolando is as follows: take a square piece of paper and fold it into a triangle (see figure) ; the angle b a c oi the triangle is 45 degrees; the edge d a is folded back on the dotted line a e; the angle d ae equals half of 45 degrees, or 22.5 degrees, and the angle r a e also equals 22.5 degrees. Unfold the paper in the line e a; in the figure thus formed h a c equals 45 degrees and eae equals 22.5 degrees; e a b equals 67.5 degrees, which is the angle desired. Place the point a in the middle line of the head over the point of origin of the fissure of Rolando; the side a b is laid along the middle line of the head, when the line a e will be found to correspond to the fissure of Rolando — all of which is somewhat confusing, not very interesting, and is much simplified by using Horsley's cyrtometer, or applying Kronlein's cranio- cerebral topographic lines. Ingenious as all this is, the surgeon, and especially the expert neurologic surgeon, seldom employs these measure- ments. Modern operations, with their large plastic openings, disclose such extensive fields of the brain that accurate external measurements are no longer needed in order that one may strike upon special areas. Let us return, therefore, to a short consideration of cerebral localiza- tion. I shall take many of the statements from Harvey Cushing's admirable essay. ^ We now know, through the accurate methods of cortical stimulation introduced by Sherrington and Griinbaum (1901), that that portion of the cortex which is directly excitable by a unipolar electrode consists of a narrow strip which lies anterior to the central fissure (Rolando), and extends to the depth of this fissure 07i its anterior surface alone. This is the true motor cortex. The central fissure divides the cortex into an anterior motor and a 'posterior sensory field. The excitomotor cortex is limited to a narrow strip of the exposed part of the central anterior gyrus, but extends to the depth of the central fissure. Its chief portion, therefore, does not lie on the visible surface, so that a lesion which involves the motor cortex may be far ovit of sight. The Rolandic fissure is not a straight line, but is broken by two or three more or less well-developed angles (genua). Opposite the two upper genua the motor strip is narrow, and its representative movements not complex — the movements of the neck and tiaink. Thus the genua are valuable surgical landmarks, particularly the middle and inferior genua, which are often brought into view in an operation. Above the uppei* ^ Harv^ey Gushing, Surgery of the Head, Keen's System of Surgerj'-, vol. iii, pp. 17-276. FRACTURES OF THE SKULL Fig. 415. — Sylvian line connects external angular process, A, with point 75 per cent, of distance A' to /. Super- ior Eolandic point, R', lies | inch behind midnaso-iiiionic point (50 per cent.)- Inferior Rolandic point, R", lies at junc- tion of Sylvian line with perpendicular to Reid's base-line, R-B, at preauricular point. Sylvian point lies at junction of Sylvian line with line from meatus to 25 per cent, of naso-inionic line cCushing in Keen's Surgery). Fig. 417. — NO = Kocher's equator- ial line, nasion to inion. XL = Poirier's Sylvian line from nasion to lambda. MA = Kocher's anterior meridian drawn 60° from meridian line at midsag- ittal point; lies over precentral convolu- tion and crosses XL at Sylvian point, Sfs = superior frontal sulcus at one- third of MA; Sfi = inferior frontal sul- cus at two-thirds of MA. MP = Kocher's posterior meridian, also 60° from midline. Lines crossing at Sts = superior temporal sulcus (Gushing in Keen's Surgery). Fig. 416. — Forty-five per cent, of median naso-inionic line = prero- landic point; 55 per cent. = Rolandic point; 70 per cent. = Sylvian line; 80 per cent. = lambda; 95 per cent, gives lower edge , of occipital lobe. Line from A, external angular process, to 70 per cent, gives Sylvian fissure. S a= Sylvian point = junction of second and third tenths of this line, while R" = inferior Rolandic point = junction of its third and fourth tenths (Cushing in Keen's Surgery). Fio-. 418. — GB = German " base- line " from inferior edge of orbit through upper edge of meatus. XJB = upper horizontal, parallel to GB through up- per border of orbit. M, C and Z = per- pendicular at posterior border of mas- toid, at condyle and midzygcma. The Rolandic line unites the points of cross- ing of the posterior perpendicular and sagittal lines, R', and the upper hori- zontal and anterior perpendicular, S. The Svlvian line bisects the angle R' SH. Inferior Rolandic point, R" (Cush- ing in Keen's Svirgery). (340 THE HEAD AND SPIXE genu there is a small triangle only of motor cortex which can be exposed. When stimulated, this ti-ianf;le shows movements in the hip, the knee, and toes. Opposite to this upper genu lie centers for movements of the thorax and abdomen. Between it and the middle genu lie centers for the upper extremity, the shoulder being represented by a center higher than that of the fingei's and thimib. Opposite the middle genu aie the centers for the neck, and below it those for the face — eyelids above and lips below, etc. The centers for the jaws, tongue, vocal cords, pharynx, etc., are lower still, usually below an inferior genu. If the above-named cerebral centers be damaged, there results a corresponding loss of motion, but sensation is not impairetl. We observe also that certain complex movements may be obtained by stimulating areas adjoining the true motor cortex. For example, one may obtain movements of sucking, chewing, sneezing, and speaking by stimulating the pars opercularis below the central anterior gyrus (this is, near Broca's vocal speech center). The pathway downward from the motor cortex is by the p3'ramidal tract, whose fibers degenerate throughout their length, if their cortical cells be injured. The sensory field lies behind the fissure of Eolando, and the re- searches of Campbell in particidar seem to show that primary registra- tion of "common sensation" occurs in the central posterior gyms. This sensory area in its relation to the fissure of Rolando occupies much the same position posteriorly that the motor area holds anteriorly. As Gushing points out, the sensory field is largely hidden from view on the posterior surface of the fissure, and does not extend back over more than the anterior half of the exposed gyrus. The fibers to this sensory field pass from the thalamus in the " cortical lemniscus " of the corona radiata. These fibers, in their course, lie in the rear part of the internal capsule. In the post-rolandic region there are registered the tactile sense, the muscular sense, and the sense for discriminating points in contact. As one goes further back on the cortex, sensations become more complex, so that deeper and more extensive lesions are needed to interpret their transmission. The senses of pain and of temperature lie probably in the intermediate postcentral zone of Campbell, and that for the recog- nition of objects — the stereognostic sense in particular — is located as far back as the parietal lobe. Visual impressions are received on the mesial surface of the occipital lobe, in the calcarine region. Auditory impulses are received apparently' in the superior temporal gyrus, and are converted into conscious perceptions in adjoining parts of the temporal lobe. The center for the sense of smell is pi'obably in the pyriform lobe, while the center for taste is not well determined, but lies presumably at the lip of the limbic lobe, in the neighborhood of the incus. There appear to he four corticcd areas concerned in speech in right- handed people. The center for the recognition of spoken words lies in the outskirts of the primary center for hearing, in the superior temporal gyrus of the left tempoi-al lobe. The centers for vocal speech are taught FRACTURES OF THE SKULL 641 by Broca to lie in the posterior end of the inferior frontal gyrus. The visual word cent(T eni])loyed in reading is in the angular gyrus, and the writing center, if such exists, is in the posterior end of the middle frontal gyrus. So far as neurologic studies have gone, the foregoing description sums up briefly our present knowledge. Other areas of the cortex appear to be concerned with complex processes of association. Lesions of these areas are largely " silent," so far as our present methods of exami- nation show us. We have already considered in some detail the symptom coma. Let us now continue a consideration of the symptomatology of or- ganic lesions. Headache is one of the cardinal symptoms of head lesions. It is common enough in other connections, but bear in mind that the one symptom, persistent headache, long continued, should make the surgeon extremely suspicious of intracranial disease. Headache is constantly present in diseases of the meninges, particularly when the dura is in- volved; and the dura takes its nerve-supply almost entirely from the trifacial. Far the more important headaches, how^ever, are those due to intracranial pressure — to tumor, edema, internal hydrocephalus, serous meningitis. Those headaches due to pressure have no relation to the seat of the lesion, as a rule. Headaches due to pressure are of all grades, from a dull sense of pressure to agonizing pain. Yomiting is the next cardinal symptom of importance. It occurs in the presence of all sorts of cerebral lesions, and may be an early symptom of concussion or contusion*. We must recognize especially the sudden projectile vomiting which is a common symptom of increased intra- cranial tension, due to brain tumor, to the edema of nephritis, etc. Choked disk (" optic neuritis") is one of the most important signs of intracranial pressure. The surgeon should look for it in all cases of head injury or suspected intracranial disease. As Gushing says, " it is not sufficient for the examiner to be able to recognize a choked disk when it is fuU blown, but the slight edema of retina and nerve head, with early distention and tortuosity of the veins which precedes actual ' choking. ' " Gushing asserts further, after an interesting discussion of the nature of choked disk, that the rapid subsidence of that condition after decompression operations leads him. to believe that almost all, if not all, cases of choked disk are primarily of mechanical origin, and are not a true neuritis. Besides the general symptoms of organic head lesions there are numerous so-called focal or localizing symptoms, which are often of ex- treme interest. There are disturbances of motion, of common sensation, and of the faculties of special sense — irritative symptoms. Motor paralysis is always the most striking and obvious of these focal symptoms. It indicates the side of the brain which is involved. Sometimes it suggests the exact situation of the lesion. It may be hemiplegic, and involve an entire half of the body, or may involve the trunk and extremities only. It may be monoplegic and involve but one 41 642 THE HEAD AND SPINE extremity. It may be paraplegic and affec-t the legs chiefly, or diplegic and impair the use of both arms and legs. Muscular spasticity with increased reflexes indicates a lesion of the intracranial portion of the motor pathway. Fui-therniore, such motor irritation is shown often by epileptiform convulsions. The process leading to convulsions may be quiescent — the cortical cicatrix of an old healed focus of hemorrhage; or the process may be progressive— a cyst or tumor. Disturbances of sensation also may result from coi-tical and subcorti- cal lesions. They may be irritative and associated with paresthesia, or paralytic and accompanied by anesthesia. A certain degree of motor impairment almost always accompanies these sensory disturbances. Such, in general terms, are the symptoms which should suggest to the surgeon some localized intracranial lesion. The reader interested in this matter should consult the larger books and special monographs, particularly those treatises which discuss in detail regional diagnosis — the symptoms resulting from damage to special areas. He should not be misled, however, into a belief that with our present knowledge we can always determine surely, and from symptoms, the exact location of an intracranial lesion. In numerous cases we can so determine, however, and in most cases we may assert positively the presence of some disturb- ing element within the skull, though we may not state its location or its character. The Meninges The meninges are worthy of our most careful study, yet must we limit ourselves to a few brief paragraphs.* One recalls certain important anatomic facts : that there is no gross communication between the sub- dural and subarachnoid spaces; that the subdural and subarachnoid spaces of the brain can be injected from the corresponding spinal spaces; that the dura carries on its outer surface certain arteries of surgical interest, and that it incloses the great venous sinuses; that the dura in the young on its outer sur- T-- ^-in oi ^ 1 t face adheres more or less firmlv to the Fig. 419. — bketch or cross-sec- , n i , • •' , tionof longitudinal sinus in itsmid- skull, and that it acts as a periosteum; course. Note width of parasin- that as a protection for the brain the Surge^r'''' ^^'"^^"'"'^ ''" ^^^^""^^ dura, owing to its smooth endothelial surface, is of great importance, and that rt is separable into two layers, between which are inclosed such stmc- tures as the Gasserian ganglia. The dura is a strong membrane, and such of its prolongations as the falx and the tentorium furnish important supports for the hemispheres. The longitudinal sinus and other sinuses 1 For a delightful discussion of meningitis, brain abscess, and brain tumor sec Charles A. Ballance's published lectures, Some Points in the Surgerj' of the Brain and Its Membranes, 1907. DEVELOPMENTAL ANOMALIES 643 lie within the folds of the dura, and into the longitudinal sinus or its expansions enter many of the more important superficial cerebral veins. In its mickllc course the longitudinal sinus expands broadly (iacuncB lat- eralea), and into these expansions project most of the so-called Pacchion- ian granulations, whose function is uncertain. They are tuft-like proc- esses from the arachnoid and contain cerebrospinal fluid. The middle meningeal artery furnishes the chief blood-supply to the dura; and its nerve-supply is abundant, coming mainly from the trifacial. Gushing believes that headaches are due to the stretching of the dura or of its expansions. The 'pia is a delicate vascular membrane which clings closely to the convoluted surface of the brain and dips into all its irregularities. The arachnoid, on the other hand, lying over the pia, bridges most of the irreg-ularities. Remember that the subarachnoid spaces thus formed are not free, but are honeycombed by strands of delicate tissue which bind loosely together the pia and the arachnoid, while the subdural spaces, in contrast, are open and free for the circulation of fluid. The ependyma is the lining membrane of the ventricular cavities — a layer of epithelial cells, mostly underlain by a thin layer of neuroglia. The cerebrospinal fluid is probably formed through the action of the ependyma. This fluid is not merely a lubricant or a water bed ; it should be regarded as the lymph of the brain, though it is a true secretion and not an exudation. It passes from the meningeal spaces into the venous circulation by means of the Pacchionian granulations, so that its chief location of exit is into the venous sinuses, DEVELOPMENTAL ANOMALIES There are sundry developmental anomalies due to failure of closure of the cranium, and into these unclosed spaces portions of the cranial contents protrude — cephalocele. This protrusion is usually in the middle line of the head, and is most common in the occipital region, though it may protrude from the anterior fontanel. According to their structure and contents we classify cephaloceles as meningocele, membrane containing fluid; encephalocele, a tumor containing mem- brane plus brain, and encephaiocystocele, a tumor containing mem- brane and brain which is itself distended with fluid communicating with a ventricle. True meningoceles and encephaloceles are extremely rare. Encephalocystoceles are not uncommon. In making the diag- nosis one distinguishes the last readily from acquired hernia cerebri, though they may be mistaken for some of the rarer tumors. An infant the victim of cephalocele rarely lives long, and even if years are added, the life is of little value. The only serviceable treatment is by operation. Frequent tappings avail little or nothing. A meningocele with a small pedicle may be removed successfully, after which the skull defect should be closed by a plastic operation with bone or periosteum. 644 THE HEAD AND SPINE HYDROCEPHALUS Hydrocephalus is a sign of disease, not a disease in itself. We speak of hydrocephalus as chronic or acute, congenital or acquired, external or internal. The acquired condition is brought about in most cases by some obstruction to the ventricular outlets, with a consequent damming back of cerebrospinal fluid. The term, external hydrocephalus, appears to be a misnomer. Acquired internal hydrocephalus may result from tumor pressure, from inflammation of the meninges and ependj-ma, or from venous stasis in the velum interpositum. Such hydrocephalus usually causes death before any great ventricular distention is reached. if >. V' /^ \ r ^ ^« 9E ^^P ^^- -■'-'■ " ' Fig. 420. — Hydrocephalus (Massachusetts General Hospital). The treatment of such conditions is most unsatisfactory, as we should expect. Sometimes ventricular puncture may relieve; rarely, lumbar puncture in the less advanced cases, though the last maneuver is dangerous. At times, relief of symptoms has followed a simple de- compres.sive operation on the skull, with puncture of the ventricle.' Internal hydrocephalus of the congenital, progressive type is most characteristic in appearance. It may be due to a congenital syphilis or to an abnormal increase in the amount of fluid secreted, or to both causes. It often accompanies cephalocele and spina bifida, and consists ^ W. W. Keen punctures the ventricle at a point corrc'sponding with the pos- terior end of the temporal Une, about 3 cm. behind and an equal distance above the external auditon,- meatus. Enter the needle in the posterior i)art of the first temporal convolution, aiming at the summit of the opposite pinna. Fluid will be found at a depth of 5 cm. CEREBROSPINAL RHINORRHEA 645 of an enormous distention of the ventricles of the brain, with a corres- ponding thinning of the cortex. The appearance of the unfortunate infant victims is striking, " the large, thin, flaring, cranial leaflets being perched on the .small facial bones like the petals of a single water-lily on its calyx" (Cashing). These heads may reach a surprising size. Three liters and more of fluid have been reported as removed. The weight may be so great that the child cannot raise his head or move it even. These children do not cry, because crying increases the intra- cranial tension and causes pain. They may become victims early of gastro-enteric disturbances, and die. They may survive as physical and mental wrecks. They have been known feebly to reach adult years. Some of the milder cases have become arrested, however, either spon- taneously or after the employment of simple tapping. These cases of hydrocephalus must be differentiated from certain cases of rachitis. In rachitis evidences of bony changes elsewhere in the skeleton should suflace to establish the diagnosis, but the two affec- tions may coexist. In doubtful cases a lumbar puncture may deter- mine the diagnosis. The treatment of congenital hydrocephalus has been the subject of no little discussion. Nothing but mechanical means will avail, and various such means have been advocated by sundry surgeons. Occasional tap- pings accomplish little, for the fluid quickly reaccumulates. Perman- ent drainage of various forms has been tried, either from the ventricles directly or through lumbar puncture. Gushing has had a considerable measure of success by his method of lumbar drainage, which is ex- tremely ingenious.^ He determines first the fact that ventricular fluid will flow freely from the lumbar regions. Then he opens the ab- domen, trephines the body of the fifth lumbar vertebra from the front, and inserts a permanent silver cannula, which shall drain the cerebro- spinal fluid fon\'ard into the peritoneal cavity. Ultimately, through processes of healing, the fluid is turned aside into the retroperitoneal space only, whence it is taken up by the radicles of the receptaculum chyli, as experimental observations have showTi. This operation, of which Gushing reports 12 cases, is as yet too recent to give us definite knowledge of ultimate results. The method is applicable to selected cases only — those in which the foramina of Magendie and Luschka are open. Such is the status at the present writing of the interesting and obstinate condition — internal hydrocephalus. CEREBROSPINAL RHINORRHEA A curious but rare discharge of cerebrospinal fluid from the nose has received the appropriate name of cerebrospinal rhinorrhea. This may be clue to an injury, to a chronic hj^drocephalus, or may occur spontaneously. The condition is serious because it may lead, through the open nasal channel, to an infection of the meninges from the nasal passages. The discharge may be abundant or occasional. The condi- ^ Keen's System of Surgerj^, vol. iii, p. 123. 646 THE HEAD AND SPINE tion may prove quickly fatal or may last for years; and. most unfor- tunately, we have no means of treating it. Before considering inflanmiation of the meninges (meningitis), let us discuss inllammations of the meningeal veins, and especially of the sinuses — inflammation, which leads to thrombosis. SINUS THROMBOSIS Sinus thrombosis is a serious malady. Rarely it may be primary (marasmic) and pass unrecognized while the patient lives. This form of thrombosis occurs in debilitated persons, especially in infants and the aged. The disease may spread and involve numy sinuses. If thrombosis occurs in the straight sinus, it will set up most profound intracranial disturbances. Since the disease occurs commonly at the end of long illness, the symptoms are not marked, and such as they are, they may suggest brain tumor. Sinus thrombosis from an injury, non-septic, occurs rarely also. Gushing records two notable cases of non-septic cavernous sinus thrombosis, one of which occurred after an operation upon the Gasserian ganglion. Thrombosis of this sinus results in an exoph- thalmos with extreme swelling and ecchymosis of the lids and con- junctivae. BUndness is almost inevitable. Extensive non-septic trau- matic thrombosis is associated with somewhat sudden symptoms — headache, dehrium, stupor, perhaps vomiting and convulsions, and early choked disk. Infective sinus thrombosis follows most commonly some form of chronic suppuration elsewhere — especially suppuration in the sphenoid cavities, the antrum, the mastoid, and the middle ear. Probabl}' chronic otitis media is the cause of sinus phlebitis in two-thirds of aU cases of such phlebitis, and the process seems to be more frequent on the right side. The sinuses close to the ear become involved first in inflamma- tion resulting in thrombosis, and the process spreads, extending to the lateral, the sigmoid, and the sagittal sinuses, and into the jugidar vein in the neck even, or the petrosal and cavernous sinuses may be the first vessels affected. The symptoms of septic sinus thrombosis follow upon the long- standing chronic evidences of the initial disease (in ear, antmm, or elsewhere) and spread rapidly. There are chill, headache, nausea, dizziness, and vomiting. The temperature nms high, with remis- sions. The pulse is rapid. There are sweating and leukocytosis. The thrombus may break down, and septic particles may be carried into the general circulation, with a resulting pyemia. Abscesses de- velop in the lungs. The patient's mind may remain clear unless menin- gitis or cerebral abscess supervene. One may not always and readily make a diagnosis of thrombo- phlebitis in the sinuses. Of course, the diagnosis may be easy when the source of the infection — in the ear or elsewhere — is discovered, and when there are present such obvious symptoms as tenderness along MENINGITIS 647 the jugular vein; pain, tenderness, and edema behind the mastoid; sudden exophthalmos and chemosis; paralysis of nerves, and the like. But these symptoms may not appear until late, and the disease may be mistaken earh' for some general systemic infection. If the infec- tion run untreated, meningeal or cerebral complications supervene, with a general pyemia, under which the patient sinks gradually and dies usually in the course of a month or six weeks. The treatment of sinus thrombosis is purely operative, and the exact point of attack is dependent upon the source of origin and loca- tion of the infection. We endeavor always, therefore, to open down upon the involved sinus and to clear it out. For example, in the case of sigmoid phlebitis the surgeon opens the mastoid cells, lays bare the sinus, and determines its contents by aspiration with a hypodermic needle. If the sinus be found occluded, the clots must be washed out. If the jugular vein is obviously involved, one may follow the brilliant method advocated by Zanfel in 1880; tie the jugular low in the neck, and wash out the clots in the vein and sinus by through-and-through irrigation. By such measures surgeons have been able to record a large number of brilliant and successful operations. MENINGITIS Meningitis proper is divided commonly into the subjects pachy- meningitis and leptomeningitis, the former indicating inflammation of the dura; the latter, inflammation of the pia arachnoid. When we consider 'pachymeningitis, we use sundry terms to indicate the area involved— pachymeningitis externa, pachj-meningitis hsemor- rhagica interna. External inflammation of the dura follows septic infections from injuries, middle-ear disease, and other local sources, and is the common precursor of internal inflammation of the dura and of the pia arachnoid. Internal hemorrhagic ^pachymeningitis is charac- terized by an easily detached membrane with numerous new-formed blood-vessels on the inner surface of the dura. The symptoms vary and ma}^ be those merety of progressive dementia, though there may coexist often severe headaches with convulsions. We have no satisfac- tory treatment for this hemorrhagic form (which perhaps should not be designated meningitis at all), though certain cases seem to have been greatly relieved by decompressive operations. The treatment of external meningitis is much more satisfactory if the diagnosis can be made. Open the skull liberally by turning back a large bone-flap in the neigh- borhood of the infected area. Irrigate gently with hot salt solution the meningeal surface, and provide suitable rubber-tissue drainage. One may thus look for a striking, though somewhat protracted, re- covery in manj^ cases. Leptomeningitis unfortunately follows dural infections, whether from traumatic tearing of the dura or from chronic bone suppurations. Moreover, leptomeningitis may be a primaiy and specific malady, which becomes generalized early. Secondary forms, on the other 648 THE HEAD AND SI'IXE hand, tend to remain localized. Leptomeningitis may be rapidly fatal in a few hours, therefore, or may run on for months. A specific foim has received the name cerebrosi)inal fever (" spotted fever"), and is due to the Diplococcus intracellularis (Weichselbaum), the ailment being frequently epidemic. It is needless here to discuss surgically this grave disease (cerebro- spinal fever) beyond pointing out the fact that certain operative mea- sures, with permanent drainage, offer promise of benefit. Lumbar puncture with the evacuation of fluid may avail if the basal foramina are open. In other cases the suboccipital drainage through trephining beneath the cerebellum, a method suggested by Charles A. I^allance, seems to be preferable. A further and still more promising measure is to tap the ventricles in the manner I have already described. This subject is still under discussion, however, at the present writing, and Fig. 421. — Lumbar puncture (C'hipault): A, Method of Quincke; B, method of Marfan; C, method of Chipault. The simplest plan seems to be to puncture between the fourth and fifth lumbar vertebrse. The space between these vertebrip corre- sponds to the highest part of the iliac crests. Chipault, however, maintains that tl e lumbosacral space is preferable, since it is the largest, is surrounded by good land- marks, and is opposite the terminal enlargement of the dural sheath (Ballance). I refer the interested student to the larger treatises on surgery. Hap- pily, the serum treatment of Flexner is now^ supplanting all operative treatment. Suppurative leptomeningitis concerns the surgeon especially, and the diagnosis of this condition is not always obvious. We may early confound it with " meningitis serosa," an extremely interesting condi- tion described by Quincke in LS93. Meningitis serosa is not associated with suppuration, though there appears an abundant serous exudate, an increase in cerebrospinal fluid, injection of the meninges, and symp- toms of intracranial pressure, which, if not relieved, may lead to death. In these cases lumbar puncture is our trump card. Lumbar puncture alone will serve to establish a diagnosis, and if the withdrawn fluid be sterile, drainage frequently will result in a cure of the serous meningitis.^ 1 The cuts in the text illustrate admirably satisfactory methods of lumbar punc- ture, Charles A. Ballance, ibid. MENINGITIS 649 In suppurative loptomoningitis we find commonly the streptococcus, the Staphylococcus aureus, alhus, and citreus, and sometimes the Bacil- lus pyogenes foetidus and other rarer organisms. The symptoms of purulent forms of meningitis present a picture which is sometimes characteristic and sometimes obscure. Commonl}-, fever begins within forty-eight hours of the infection, and rises gradu- ally, running up to 104°, 105°, 106° F.; the pulse is quick, full, and bounding, and there are superadded the other familiar signs of intra- cranial pressure — headache, vomiting, choked disk, paralyses, and vary- ing focal symptoms. Operative treatment of suppurative leptomeningitis may cure, though the disease is still justly regarded as one of the most fatal known to us. Nevertheless, I have had brilliant recovery follow a liberal exposure and drainage of the meninges, the opening of the skull being made to depend, so far as possible, upon the original site of in- Fig. 422. — Sketch showing method of lumbar puncture. A line joining the highest part of the iliac crests bisects the space between the fourth and fifth lumbar vertebrse. This is the best guide in lumbar puncture. A fine hollow needle, 7 cm. long, is re- quired (Ballance). fection. I reported in 1906 a case of leptomeningitis following fractured middle fossa, with a gradually resulting delirium associated with right- sided paralyses and incoherence of speech. I opened the skull and dura over the left Rolandic area, drained the field for some days, and was rew^arded by the complete recovery of the patient. Irrigation is not to be commended. Frequently acute internal hydrocephalus com- plicates meningitis, when one must resort promptly to puncture of the ventricle. From a considerable experience of my own, and from the records of other surgeons, I am convinced that the time has gone by for abandon- ing to their fate patients critically ill with meningitis. The disease is comparable to diffuse peritonitis. The patients wall die if let alone. Occasionally they recover if prompt drainage be boldly instituted, sup- plemented by the exhibition of urotropin. The ependyma lining the cerebral ventricles is subject to infection, 050 THE HKAD AND .SPIXI-: and the resulting ependymitis is seemingly a specific malady, without any known association with meningitis. Gushing observes that these ependymal inflammations doubtless play a large part in hydrocephalus, and have received less attention than they deserve. The inllamma- tions result in a sudden closure of one or another of the ventricular channels. Immediately symptoms of acute hydrocephalus supervene, with the familiar signs of intracranial pressure — headache, vomiting, and choked disk. It is usually impossible to attack directly the source of trouble, but almost always an extensive decompressive operation will relieve the symptoms. Occasional cure may result. Sometimes aspiration of the ventricle at the same time will be advantageous. Tuberculous and syphilitic meningitis are not generally regarded as surgical ailments, and their discussion here may not be appropriate, but one word regarding treatment is in place : The mechanical disturb- ances from pressure should be met by lumbar puncture, and when hydrocephalus is present, by ventricular puncture. In the case of syphilitic meningitis operative treatment should be preceded by a thorough course of potassium iodid, but this should not be persisted in to the neglect of operation for more than three weeks if there be no relief from the symptoms. Occasionally gummata may be attacked directly, but even when they are not found, decompression frequently wall relieve the symptoms. MENINGEAL TUMORS Meningeal tumors occasionally are seen. If they spring from the pia arachnoid, they frecjuently can be located readily. If they are of dural origin, their position may not be so obvious. These latter tumors are often of the most malignant sarcomatous nature. They attack the cranial bones, and may penetrate them and appear externally as soft, pulsating swellings. I shall consider further this subject in connection with cerebral tumors. The Cranium Diseases of the cranium belong as properly with meningeal disease as with scalp disease. We have just seen that certain malignant growths of the meninges may penetrate the skull from within. There are numerous other maladies of the bones which the writers describe — atrophy, hypertrophy, acromegaly, gigantism, osteitis deformans, osteomyelitis, cranial syphilis, and tuberculosis. All these are subjects which I pass over with their mention merely, and with the suggestion that they are not often amenable to surgical treatment. TUMORS OF THE CRANIAL BONES Tumors of the cranial bones merit some further notice, however. Osteomata are not especially uncommon. They are benign tumors. TUMORS OF THE CRANIAL BONES 651 hiird or soft, and arise either from the periosteum or from the cartilage. "Exostosis" is the term commonly applied to them. They may be external or internal. They may be multiple or single, and they vary in size from minute nodules to large, irregular, flat, or pedunculated masses. When on the inner surface of the skull, they may reach a con- siderable size without producing symptoms; or they may cause notable symptoms either of general pressure or of focal disturbance. They may appear in the accessory sinuses of the ethmoid and sphenoid, fill these cavities, and invade the neighboring spaces — the orbit, the nares, or the base of the skull. These latter osteomata are composed of a shell covering a central spongy portion. Generally they are recognized easily, but sometimes one mistakes them for sarcomata. If osteomata are not unsightly and do not cause symptoms, they may be let alone; but if they are troublesome, the surgeon may under- take their removal. The removal of osteomata is not always easy and may be extremely dangerous, for the whole thickness of the skull may be involved, and in the case of tumors of the cranial sinuses, opera- tion may be followed by septic infections. Writers have recorded a high mortality. The surgeon should consider carefully the question of drainage, and should certainly employ it in the face of suppuration and hemorrhage. Malignant tumors of the cranial bones occur occasionally. Sarcomata may be primary there or secondary, and hypernephromata have been reported. Sarcomata and hypernephromata occur at all ages and in both sexes. Primary sarcomata arise from the diploe or from the dura, and abundant new bone-formation may be associated with their growth. It is an extremely interesting fact that their beginnings often seem to be associated v/ith traumatism, so that the surgeon must bear in mind the possibility of present sarcoma when dealing with old head injuries followed by persistent local pain and symptoms of intracranial pressure. Unfortunately, early diagnosis of these internal malignant growths is generally impossible except through an exploration of the skull, and here again is a further reason for operat- ing early in cases of obvious and pronounced cranial or intracranial disturbance. Bloodgood has shown that, with the exception of myelog- enous sarcomata, operations for sarcoma, even on the extremities, are futile. The same observation probably would hold true in the case of the skull. Myelogenous sarcomata, however, may often be cured by a purely local operation— excision or curetting even. Cancer of the skull is always a metastatic process, except in those cases in which the skull is attacked by direct extension of cancer from the scalp. Myeloma (Kahler's disease) is interesting, though little under- stood. It is a multiple tumor-forming disease of the marrow, associated with absorption of bone, pathologic fracture, and grievous deformities. As yet it is incurable and is recognizable by the presence, in the urine, of an albuminous body named from its discoverer, Bence-Jones. Mye- loma of the skull is merely a local expression of a general disease. 652 THE HEAD AND SPINE The Brain We are wont, in discussion, to distinguish injuries of the bniin from diseases of the brain, and, for the sake of convenience perhaps, such a division of the subject is permissible. In fact, however, one cannot always divide injuries from diseases in any arbitrary fashion. Nor can we group brain lesions always apart from lesion of the brain's en- velops and bony shell. The whole subject of the nomenclature of brain lesions is one of continually increasing difficulty and confusion the nioie we attempt to Hmit these considerations by arbitrary anatomic terms. We must study the head as a whole, but we must not depart so far from conventions as to make our discourse unintelligible. Hitherto in this chapter nominally we have dealt with the skull and the meninges, but inevitably we have been obliged to consider the topography and injuries of the brain, and we have constantly been bearing in mind the fact that damage to the skull and meninges is important only, and so far as it cripples the brain itself. Let us now advance more deeply into the field and consider diseases peculiar to the brain — inflammations and tumors and the remote results of certain brain lesions. ENCEPHALITIS Acute encephalitis ^ may exist, though it is not common. According to Striimpell, the process is similar to the acute poliomyelitis of the cord; the symptoms are those which accompany all severe, acute cerebrospinal affections, and are due to the intracranial tension — with headache, stupor, vomiting, fever, delirium, rapid pulse, and, in the graver cases, choked disk, coma, slow pulse, and stertor. There may be paralyses or epileptiform seizures. Children are the victims com- monly, and they may recover as physical and mental cripples. Treatment hitherto has been of little value, though Cushing records his opinion that an extensive decompression operation may be of service. A much more common form of infection of the brain is that illus- trated by cerebral abscess. CEREBRAL ABSCESS I have already hinted at the development of brain abscess as the sequel of local bone disease — in the middle ear, the mastoid, the frontal sinus, etc.; or abscesses may follow traumatic injuries to the head, and rarely some general infection, such as is set up by a suppurative pneu- monia, by influenza, by typhoid fever, or by tuberculosis. Some of these abscesses are of slow development and long duration. Charles A. Ballance especially dwells upon that form of abscess which may be likened to the shirt-stud felon. In such a case the infection penetrates slowly through the cerebral cortex, burrowing, as it were, and leaving a track behind it. Deeper in the brain, in the white substance, the * This disease appears to be growing increasingly frequent and to develop in epidemics. The year 1909 saw a great number of these cases in both America and Europe. TUMORS OF THE BRAIN" 653 advancing infection spreads out rapidly in the softer tissues, producing the effect of a mushroom-shaped mass. Ballance reminds us also that brain abscess or sinus infection is a more common complication of chronic ear disease than is acute meningitis, whereas meningitis f]-ecjuently has followed unskilful attempts to remove a foi^eign body from the ear. The abscess may increase rapidly and break through all barriers into the ventricles, or outward to the brain surface, or it may i-un a chronic course with few striking symptoms. A chronic abscess is encapsulated and may persist for months or years even. When symptoms of brain abscess appear, they are due to three factors — the presence of pus ; the increased tension within the skull; the interference with or damage to function; so that we shall expect fever, chills, and vomiting; headache; choked disk ; paralyses, anesthesia, convulsions, and loss or impairment of the special senses. One should attempt to disting-uish, therefore, between cerebral abscess and such other inflammations as meningitis, ependymitis, and septic sinus thrombosis. Such differentiation fre- quentty is impossible until actual exploration has revealed the tiaie condition. Brain abscess, like abscess elsewhere, must be treated by operation. We must evacuate pus. In the case of brain abscess, however, unlike abscess elsewhere in the body, we find ourselves dealing with a circum- scribed collection of fluid which lies in an almost fluid medium. As pus flows out brain flows in, so that complete and thorough drainage is not easy. Moreover, our operations must be determined often by the source of origin of the abscess. Local bone disease must be investigated and removed; the further course of the spreading infection must be followed into the brain — if necessary, after a considerable removal of the bones of the skull; and the abscess, wherever found, must be thoroughly evacuated. As Gushing says: " Unfortunately, these opera- tions continue to be conducted as a last resort in the ' manifest ' or even near the terminal' stage of the disease. They should, on the other hand, be undertaken early without waiting for unequivocal symptoms." Surgeons differ in their views regarding methods of exploring the brain for abscess which is not immediately apparent — whether to explore with a trocar or with a narrow-bladed knife. I am inclined to accept the dictum of Ballance, who advocates the use of the knife. After the pus is found and evacuated, we must institute gauze drainage, and the gauze should remain long in position. And we must not forget that there may be multiple abscesses, in which case the drainage of one may not be followed by the prompt relief of symptoms for which we looked. Then, again, if the patient's condition permit, there is no resource save another operation.^ TUMORS OF THE BRAIN Ballance, in his splendid lecture on brain tumors, remarks: "It would be impossible, in the course of a single hour, to give any adequate ^ The admirable essays of Ballance and Gushing should be read by the surgeon who is planning one of these difficult operations. 654 THK HEAD AND SI'INE account of so vast a subject as that of intracranial tumors." Our statements in this chapter accordingly must be of the briefest possible nature. Here is Ballance's classification of intracranial tumors, the majoiity of which are of surgical importance: INTRACRANIAL TUMORS. I. Epiblastic tumors: A. (Vrclji-omii. B. Glioma, gliosarcoma, anirioglioma. C. Kjiithelioma. Dtnolopod from tlio cintlicHum of the epondyma, the choroitl plexus, the pineal gland, or the pituitaiy body. D. Cholesteatoma vera. II. Mesoblastic tumors: A. Sarcoma — of skull, of meninges, of brain substance (probably arising from the walls of the intracerebral vessels), of the pineal gland, of the pituitary body. B. Endotlielioma^meningeal (the fibroplastic tumor of Lebert). C. Fibroma; fibrosarcoma. D. Psammoma; angiolithic sarcoma. III. Secondary tumors; metastases from carcinoma or sarcoma of other regions. IV. Cysts: Simjjle cysts, hemorrhagic cysts, parasitic cysts, intra- and extra- dural dermoids. V. Tuberculous tumors. \T. Gummata. VII. Vascular tumors — aneurysm. Of all these tumors, the infectious granulomata (tuberculous and syphilitic) are far the most common in our records. The tuberculomata are usuall_y multiple, varying in size, and with a thick capsule which lends itself to enucleation. These tumors are most common in the cere- bellum and in children. Syphilomata are most common in adults and are resistent to medication. They are dense, usually superficial, some- times large and multiple ; often they may be removed easily. The commonest forms of true neoplasms are the endotheliomata, loosely attached, encapsvdated, meningeal tumors which do not form metastases. They do their damage by pressure. A common seat is in the cerebellopontine recess, and they are favorable growths for excision. Gliomata form a class by themselves. They are of the epiblastic type, and arise from the neurogliar connective tissue. They are soft, infiltrating growths, which may reach an enormous size and may degen- erate and become cystic. They are vascular and frequently are the seat of hemorrhages, so that a so-called '' stroke of apoplexy " may be the first indication of their presence. Cystic tumors of a parasitic type (echinococcal or hydatid) or traumatic cysts occasionally are reported. They also give pressure symptoms, and may appear in any part of the brain. Such are the commoner forms of brain tumor. Besides these, brain cancers occur, usually from metastasis, and true sarcomata as well. We know little of the cause of the various primary tumors beyond the fact that great numbers apparently owe their origin to some cranial injury. The brain may be greatly displaced by these gi-owths, more especially the cerebellar growths, and the crowding down of the cerebel- lum and medulla into the foramen magnum, which follows lumbar TUMORS OF THE BRAIN 055 puncture in certain cases of brain tumor, probably accounts foi' the sudden deaths reported as following this little operation. In arriving at the diagnosis of intracranial tumors we study the symptoms muler two headings: general symptoms due to the increase of intracranial tension; and special or localizing symptoms, which depend upon the part of the brain involved. The general symptoms of brain tumor are those which we should expect fron:i our knowledge of intracranial pressure. The presence of a slowly growing tumor raises gradually the intracranial tension, so that commonly we do not see those acute alarming symptoms which are pro- duced by the sudden pressure of a fresh intracranial hemorrhage. Though the symptoms of brain tumor develop gradually, and though the tumor may cause actual destruction of brain tissue, either by pressure or invasion, in the end severe and alarming symptoms develop which end only in death. The general pressure symptoms, then, are headache, nausea and vomiting, and choked disk ending in blindness. Observe especially that many of the symptoms of acute lesions are absent — a high blood-pressure, a slow pulse, and stertor. These general symptoms, without localizing signs indicating the position of the tumor, may be present irrespective of the size, shape, and place of the growth. Frequently one may feel sure of the presence of a tumor, but may be quite unable to name its location when it lies in a so-called " silent area" of the brain. Moreover, a minute tumor may obstruct the foramina and cause an internal hydrocephalus, with result- ing general symptoms, but no localizing signs. Consequently, tumors lying below the tentorium may lead early to pressure symptoms, while frontal tumors may cause no disturbance until they have reached a con- siderable size. The headache due to pressure upon the dura or its expansions is usually dull and diffuse, but may be insufferably violent. The vomiting may be frequent or rare, and is irrespective of food. Choked disk is probably due to mechanical pressure, to the stasis of cerebrospinal fluid leading to the optic sheath, and consequent destruction of the nerve. For this reason the term optic neuritis obviously is not justified. One or more of these general symptoms may be lacking in cases of brain tumor, though some degree of headache is usual, especially as a late symptom. Localizing symptoms may or may not be present, as we have seen; and their localization depends obviously upon the tumor's presence within or near the various cortical centers which we have already studied. Localizing symptoms may appear early, resulting in such phenomena as Jacksonian epilepsy or focal palsy, which should lead the surgeon to a prompt exploration. So far as regards cortical growths, it is need- less here to dwell further upon the phenomena which they excite. Tumors of the basal ganglia, if they lead to pressure on the internal cap- sule, produce hemiplegia, hemianesthesia, hemiataxia, or hemianopsia. Lesions of the thalamus frequently cause athetoid movements or tremor of the opposite limb. The deep reflexes may be increased; the super- ficial may be absent — Babinski's toe phenomenon in particular. Tumors 656 THE HEAD AND SPINE of the corpora quadrigcniina load to a stajijioring gait, to a tendency to fall to one side and backward, to a failuie of sight and hearing, and to sundry palsies of the eye muscles. Tumors of the crura cerebri, of the pons, and elsewhere in the midbrain, are not accessible for removal, and usually are unsuitable for decompression, according to Cushing, because they lead to obstructive liydrocephalus, which renders ineffectual the usual palliative measures. Cerebellar tumors are frequent. Often they are accessible, and are, as a rule, localizable. Early thej^ cause general symptoms from closure of the iter, so that there results choked disk. We must dis- tinguish between extra- and intracerebellar tumors. The latter (intra- •T^mir*^.^ H. Fig. 423. — Case of cerebellar tumor. Note dull faoies and expre.ssion of eyes (Massa- chusetts General Hosjntal). cerebellar) cause pressure symptoms, but they cause vertigo also, with the apparent movement of the individual or of surrounding objects. There are focal symptoms — muscular disturbances on the same side of the body as the lesion; a staggering gait, a tendency to fall toward the affected side, nystagmus, tilting of the head, and occasional convulsions. Often there is local tenderness under the occiput. Cranial nerve s}-mp- toms usually are absent. Extracerebellar tumors, on the other hand, produce cranial nerve s\mptoms. Those tumors which are removable frequently lie in the cerebropontine recess. They are supposed to arise from the acoustic nerve, so that tinnitus with one-sided deafness is often the first symptom. They enlarge slowly and may last for years, with TUMORS OF TIIK UKAIN .057 resultiiiii' pressure paralyses of the fiicijil, iibducens, or trigeminal nerves. Eventually, they nui}' close the itei". Pituitary body tumors, lying back of the optic chiasm, affect the fibers passing to the inner side of each retina, antl lead to bitemporal hemianopsia. Acromegaly may be associated with pituitary tumors, severe headache is common, and vomiting. We see then that there may be a great variety of definite symptoms, a puzzling absence of symptoms, and a confusing presence of contra- dictory symptoms when we undertake the diagnosis of brain tumors. Moreover, certain other lesions may simulate tumors- — abscess, gumma, hydrocephalus, and the cerebral symptoms of chronic nephritis. The course of brain tumors varies obviously with their nature and their location. A non-malignant tumor may progress slowl}^ and exist for 3"ears without special disturbance if it be located in a silent area. On the other hand, an infiltrating tumor (glioma) may progress rapidly from the start. Writers describe relief of pressure by natural processes — rare processes, indeed — either in childhood, by separation of the cra- nial bones and protrusion of the tumor; or an any time of life, by de- traction of the overhang skull through atroph}' and extrusion of the tumor. The average duration of life in cases of brain tumor is estimated at three years. The treatment of brain tumors has only recently begim to emerge from a position of almost hopeless chaos, and to-day even many com- petent general surgeons are skeptical of any practical benefit from opera- tions. I cannot believe that their attitude is justified. A little retros- pection reminds us of many other surgical conditions now benefited by operation, toward which operations the profession was long skeptical. And disease of the brain furnishes a branch of surgery- peculiarly diffi- cult of diagnosis as well as of operative treatment. In general terms, w'e have now three well-recognized measures at command for our attack upon brain tumors — medicinal treatment, palliative operative treatment, and curative operative treatment. Medicinal measures are sometimes extremely efTective, but are effec- tive in the case of one class of tumors only — syphilitic gummata. We have seen that gummata are common. Sometimes it is easy and con- soling for the practitioner to persuade himself that the suspected tumor is a gumma. Often he relieves the symptoms by a vigorous course of potassium iodid. But let him bew-are of overconfidence and of incon- siderate overdrugging. If the symptoms do not promptly — within the month — show^ signs of abating, he must reflect that the tumor is either not a gumma or is a gumma of such a character that potassium iodid will not dissipate it. Moreover, let him not neglect the condition of the patient's eyes. In the case of a gumma even there may be so long a delay in the relief of pressure through medication that the affected optic nerves may go on to complete degeneration, so that the patient is cured of his tumor, but is left blind. A prompt decompressive operation might have relieved the choked disk and have saved the eye-sight. Palliative decompressive operations are extremely valuable in nearly 42 658 THE IlKAD AND Sl'l.NE all classes of brain tumors except those which, thi-ough pressure upon the iter, have caused an obstructive hydrocephalus. In these cases the newly formed cranial defect gives but temporary rehef, if any; more fluid accumulates in the ventricles, and the old high tension returns. In many cases of Ijrain tumors, however, decompression gives brilliant results, even though the patient eventually die, uni'elieved of his tumor. After the decompi-ession, headache disappears, vomiting ceases, the eye- sight is restored, paralytic conditions improve, and often the patient is enabled for a year or more comfortably to go about his business. The undiscovered tumor may continue to grow, but the great gap in the skull provides for escape of the brain as a heniia, and the old intra- cranial tension does not return. These palliative operations are undertaken in the case of presenting irremovable tumors as w^ell as of those which cannot be localized. The surgeon should take some pains in selecting the site for decompression, because the extruded brain is wont to become more or less functionless. As a general rule, therefore, one should operate over a silent area, in right-handed patients, under the right temporal muscle in case of a cerebral tumor, and under the suboccipital muscles in case of a sub- tentorial growth. Curative operations are rare, but with increasing exj^erience such surgeons as Victor Horsley, Gushing, Ballance, and others are demon- strating that certain varieties of tumors may be removed entire, with a fair chance of permanent cure. As Gushing says, certain important questions are always raised in case one is able to cut down upon and explore a tumor of the brain: What is the tumor's nature? how great a loss of function has it produced already? will its removal result in the improvement or in the increase of sj-mptoms already present? One may not answer accurately these queries in every case, but we may state in general terms that an encapsulated tumor can be removed entire, while an infiltrating tumor must be left in part. There may result immediately an increase in functional disturbances, but growing experience in operations and through animal experimentation has de- monstrated that damaged brain often shows a surprising power of re- establishing function apparently lost. RESULTS OF INJURIES AND DISEASES OF THE BRAIN Before considering in more detail methods of operating upon the brain, let us observe hei-e certain results of injuries and diseases of the brain. Hernia cerebri and fungus cerebri are sequela^ of quite different types, though their nature has often been misunderstood. Heniia is due to pressure from within, and is a proti-usion of normal brain, covered with sound skin. A fungus is a protioision of brain through an open wound in the scalp — a serious condition, owing to the prospect of infec- tion and meningitis. Gushing calls attention to the existence of a wide-spread, but curi- RESULTS OF INJURIES AND DISEASES OF THE BRAIN 659 ously erroneous, notion that mere exposure of the brain, on opening the dura, will alwaj's lead to a protrusion of brain through the dural Fig. 424. — Fungus cerebri following exploration of brain (Massachusetts General Hospital). Fig. 425. — Hernia cerebri. opening. Quite othenvise is the fact, for normally the brain recedes when exposed, owing to atmospheric pressure. Under certain circum- stances, however, the brain will protrude — perhaps from the presence 660 THE HEAD AND SPIXE of a tumor, perhaps from venous stasis, i)eihaps from an improper handling of the cortex, leading to edema and increased pressure. Under these conditions the surgeon ma}- find it impossible accurately to re- place the dura, but generally relief of tension ma}- be secured In- elevating the head, b}- pricking the arachnoid so as to allow cerebro- spinal Ihiid to escape, or, if necessary, by a lumlxir puncture. The hernitc established by decompression may reach enormous size, especi- ally if they are unprotected by overlying muscle. In these days a fungus rarely is seen. Epilepsy. — This is no place in which to discuss fully that most diffi- cult and often indeterminate disease, characterized by the symptom- complex convulsions, and conveniently called epilepsy. "Epilepsy" itself is no proper term to designate the disease. Epilepsy — a '' falling on" — is but a s>'mptom. The causes of many epileptic or epileptiform attacks are numerous and obscure, varying from psychic disturljunces to true histologic changes in the motor cortex. We must believe it proved that certain reflex irritations, as from an ovarian tumor or an ingrowing toe-nail, may cause epileptiform seizures; and certain toxemias, especially those occurring in renal disease, may lead to convulsions. Whatever the cause of the epilepsy, it is obvious that some irritation of the cortex, whether due to psychic or mechanical causes, is at the bottom of the attack. We are concerned here, however, with those forms of epilepsy especially which are due to definite, gross, organic lesions, and we must remember that organic epilepsy, as dis- tinguished from idiopathic epilepsy, is characterized by focal or so-called Jacksonian attacks, preceded by a more or less definite aura. This distinction is not always reliable, for cases of reflex epilepsy even may have focal sym'ptoms, while actual organic cortical lesions may cause no focal symptoms. We may not discuss here the intricate subject of the causation of epilepsy further than to remind the reader that, in addition to the well- recognized etiologic factors, epilepsy may be due to meningeal adhesions following meningitis, to cerebral syphilis, to brain tumors, to brain damage following traumatism, and especially to those injuries leading to what are known as birth palsies— injuries to the infant's head over- looked at birth, but leading later to pronounced nervous and mental derangements. From what has been said, and assuming the reader's general knowl- edge of the subject of epilepsy, we see that the sym'ptoms which justify a surgical operation are often difficult and confusing. Moreover, we must reflect that an individual case, taken early, may be susceptible of cure by operation, whereas the same patient, if left a sufferer for months or years, may not be benefited in the least by a late operation, because he has formed the "epileptic habit." There are sundry types of epi- leptics whom operations may benefit, especially those persons suffering from so-called Jacksonian attacks — attacks beginning with a distinct aura and marked by convulsions strictly localized at first to the hand or foot, and later perhaps becoming general. Then there are the cases RESULTS OF INJURIES AND DISEASES OF THE BRAIN 601 in which the seizui'o is general from the outset, though these cases themselves may earlier in their careers have been marked by distinctly focal symptoms. The cases of focal epilepsy — Jacksonian — appear to be due to a cortical irritation occasioned by some form of obvious lesion — depressed bone, meningeal adhesions, a tumor. Those cases distinguished b}' general convulsions may likewise be due to focal irrita- tions, and it is in this class that we nuiy often group that large number of birth palsies sometimes called idiopathic cases. The treatment of epilepsy is operative so far as the surgeon is con- cerned, though there are cases which undoubtedly have been greatly benefited after operation by resorting to the use of bromids or psycho- therapy in order to break up the epileptic habit. There is a diversity of opinion as to what should be the nature of an operation upon tlie brain for epilepsy. One fact is certain, that the old-fashioned, small trephinings, the peeping at the brain through a little hole, and the scratching of the arachnoid with a needle-point, are of little benefit. The main reason for discouragement over the history of the operative treatment of epilepsy lies in the fact that the operations have been utterlj- inadequate. Whatever the nature of the intracranial lesion may be, we have not yet determined how it affects nervous tissue so as to produce convulsions. There are those who believe that the presence of an adhesion alone is sufficient cause for irritation leading to convulsions. There are others, notably Kocher, who assume that the local lesion in itself is non-irritating except when, from any cause, a slight increase in the intracranial tension induces a special irritation at the site of the local lesion. My own experience in operating for epilepsy leads me to agree with the teachings of Kocher. AVhatever one's views on this difficult point, all competent surgeons are now agreed that in operating we should cut down on the brain through a large bone-flap. Horsley, Gushing, and others have con- ducted considerable operations upon the meninges and the brain itself for epilepsy, going so far even as to remove small areas of the cortex which were thought responsible for the focal sj'mptoms. Other sur- geons have contented themselves with removing obvious abnormalities, and trusting to extensive decompressive measures to lighten the brain of future pressure and local irritation. This last is Kocher's teaching. Certain it is that through both methods great numbers of patients have been improved or cured. Mark the distinction in the methods of finishing the operation. By the Horslej' method the dura and bone are carefully returned into place. By the Kocher method the dura is replaced, but the bone-flap is removed entirely. A great deal has been said and written regarding the importance of replacing smoothly and accurately the dura. In two cases I have been obliged to remove the dura, leaving the arachnoid to become adherent to the skin-flaps, a condition which is usually represented as leading to serious subse- quent cortical irritation. In both of these cases no disturbance has resulted, as the wide removal of bone provides for comfortable expan- sion of the brain. In spite of such experiences, however, sound practice 662 THE HKAI; AND SPIXE teaches that when it i?; possible, we should secure a smooth replacement of the dura in order to avoid adhesions. The conditions one finds within the skull — the conditions presumably causative of the epilepsy — are numerous, and sometimes obscure and puzzling. Depressed frag- ments of bone, adhesions, and tumors are ob\ious enough, but fre- quently one finds nothing beyond a wide and somewhat indefinite thickening of the arachnoid, giving to its surface a slight bulging a.' >^1 .JH i Fig. 429. — Opening the skull — .step 4. Osteopla.stio flap and dura refleeted. Note broad level of Uf)per edge of bone-flap, also concentric, rather tl'an superim- posed, openings througli scalp, cranium, and dura (Cushing in Keen's .Surgerj-). controlled near the site of their section b}' delicate, split, black silk liga- tures, needled around the vessels, and not b}' hemostatic forceps. In- deed, in all these manipulations of the membranes and cortex the greatest delicacy of touch should be practised. Rough handling ma}' frustrate all our purposes by stimulating hemorrhage and even by bringing about a troublesome edema. If the patient's blood-pi'essure falls after the skull is opened, and if signs of shock appear, it is proper to close the wound and to complete the operation some days later — indeed, some surgeons employ two or three sittings as a routine measure. The closure of the wound is an important step, not to be slurred, Whenever possible, the dura should be accurately and carefully stitched into place. When permanent decompression is required, this replacing IXTRACKANIAL Ol'EKATIOXS (){)', of the durii may be inadvisable, and if the dura is to be removed, it should be trimmed away close to the bones' edge, lest pressure from within crowd it against the rough bone and cause troublesome headache. Then one should suture the scalp accurately and carefully in its turn, and I be- lieve it is best to control all superficial bleeding points in the scalp be- fore suturing is done. If drainage must be established, we should use cigaret wicks led out through a special stab-wound beyond the edge of the skin incision, and as low down on the head as may be. Finall}-, the head should be dressed in an abundant absorbent, elastic com- pression dressing, to be changed on the third day, when all stitches and drains should be removed. After ^ — — r^ , ^.. . ... all operations on the brain, and es- pecially after traumatic lesions, give the patient urotropiii (gr. 7^ t. i. d.), which shall anticipate and check any possible infection. Decompressive operations, whene\-er possible, should be done through muscle tissue. For ex- ample, in case the surgeon plans a decompression to palliate the symp- toms of a cerebral tumor of un- knoT\-n site, he ma}* make his open- ing through the squamous portion of the temporal bone, and approach that bone by splitting the temporal muscle. B}' this maneuver one may expose a considerable area of bone, may excise it, and may cover in the gap with temporal muscle, aponeurosis, and skin, thus delimit- ing and controlling an excessive hernia. Suboccipital explorations are well made through an approach by Cushing's cross-bow incision. In this fashion, as the drawing illustrates, one maj^ lay bare comfortably the lower portion of the occiput and may remove bone, covering in the gap subsequently by heavy layers of muscle and aponeurosis. Surgeons approach the base of the skull by other routes and in other quarters — the anterior fossa through the temporal bone or even through the frontal bone; and operators have sought the pituitary fossa by going 'directly under the front allobes after turning down a large frontal bone- flap, or by working through the nasal passages and accessory sinuses. These operations about the base are almost always associated with ob- stinate, and sometimes with serious, hemorrhage from large veins, so that the operations must be undertaken with caution, pains, and discretion. It is not probable that such difficult and delicate explora- Fig. 430. — Cushing's method of clos- ing scalp before removal of tourniquet. Note ridge of tissue made by sutures when tied (.Gushing in Keen's Surgery). 668 THE HEAD AND Sl'INE tions will find favor with at a right angle to their surface, its guard (determining the de|)th of sec- tion) being entirely raised at the beginning of the division; C, knife dividing the ligamenta subflava; D, osteotome levering away the muscles of the vertebral grooves, using the spinous processes as fulcra (Bickham). and then on the other. There is sharp bleeding generally. Check it by firm packing. Before going further see that the bones are widely exposed and that all bleeding is stopped. The steps so far are tedious and often laborious. Entering through the bones of the canal is not difficult. Divide the interspinous ligament at the bottom of the proposed bone window, remove with rongeur forceps all the spinous processes in view, and TUMORS OF THE SPINE 693 cut aw;iy part ot the lowest lamina,. Then, with stout cutting forceps 1 A Fig. 441. — Osteoplastic resection of the spine: A, Tenaculum forceps holding back composite flap; B, B, delicate forceps grasping and elevating membranes and forming a transverse ridge; C, C, tenacula holding apart edges of incised membranes; D, angular scissors used in incising membranes; E, half-button of bone bitten out of lower margin of last lamina in flap by rongeur forceps; F, similar half -button bitten out of upper margin of next stationary lamina below, the two half-buttons forming a circular opening, when in contact, for drainage; G, vascular fatty areolar tissue covering membranes. The stump of the excised spine is sho's^^l, in impression, through the turned-back flap (drawn from cadaveric operation) (Bickham). (or with chisel, osteotome, or saw), cut away a suitable number of laminae on either side, and remove the excised sections of bone. 694 THE HEAD AXD SPINE Now we have the dura exposed and may see the nerves emerging from it. The remainder of the operation is obvious enough, and its exact nature depends upon our purpose in opening tlie spinal canal. We elevate or remove bone fragments, open the dura, inspect the cord, see to our hemostasis, excise, if necessary, painful nerve-roots and tumors (suture the severed cord if we hold to the strength of an erroneous conviction) , and, al)ove all things, provide adequate drainage, lest operative blood and clots pressing on the cord leave our patient's last state worse than his first. In all this we must handle the nerves, dura, and cord with such care as to avoid the common and needless bruising, and we must repair with fine gut stitches our operative rent in the dura. The closure of the wound and the dressings are commonplace matters, but in the after-treatment we must observe the same solicitude that I have enjoined for the care of fracture-dislocations of the spine. Several experienced surgeons make a bone-flap through a U- shaped incision in the skin and replace the flap m toto. I have no personal experience with this method. The results of laminectomy for intraspinal tumors are encouraging. Pain is relieved, and if the aneurilemmic fibers of the cord be not de- generated, function returns in greater or less degree. Tumors may recur, to be sure, but sarcomata even are less lial^le to recur than sar- comata elsewhere. The mortality (from meningitis and shock) is not much above 10 per cent.; and at the worst we may feel assured that death is inevitable without operation. We are justified in asserting that here is a branch of neurologic surgery already successful and full of promise. The Peripheral Nerves The surgery of the peripheral nerves is a subject comparatively recent — much more recent than is the surgery of the head and spine. Until the development of aseptic surgery, physicians thought that nerves did not lend themselves to surgical treatment so far as any power of regeneration in them was concerned. Modem studies teach us, however, that neurilemmic (peripheral) nerves are capable of regeneration and may be sutured and grafted with excellent prospect of restoration of their function. I have already in this chapter referred briefly to this matter. The manner of restoration of the structure and function in the distal portion of a severed peripheral nerve is still a subject of active controversy. We know that after the division of a peripheral nerve the distal portion regains its function even though it has been separated and isolated from its proximal portion for many months. Neurolo- gists are not in accord as to the nature of this regeneration. There is the "central theor}'," and there is the "peripheral theory." The " central theory," based on the teaching of Waller, hangs upon the neuron doctrine — on the conception of the entity of the neuron — that is to say, of the nerve ganglion with its dendrites and single axone, or NEURITIS 695 peripheral nerve filament. If this axone be anywhere divided, the "central theory" teaches that the distal isolated segment degenerates and cannot be restored to structure and function until it has reunited with the living proximal portion of the axone. The " peripheral theory, " maintained especially by Albrccht Bethe and by Ballance and Stewart, appears to demonstrate that after section of the axone, although degeneration in the distal portion does take place, neverthe- less, regeneration occurs in the same distal portion without, and in- dependently of, a reunion with the proximal portion of the divided axone. At the same time function in the distal parts is not restored until the severed parts are reunited. As Woolsey truly remarks: " Two clinical facts, the lack of regeneration, after division, of the axis-cylin- ders of the spinal cord, which have no neurilemma or neurilemma cells, and the very rapid return of sensation, after secondary suture, support the theory of peripheral regeneration." We may not discuss further this intensely interesting subject, though, as surgeons, it concerns us nearly, but we observe the fundamental fact that whatever the theory of regeneration, certain it is that divided neurilemmic nerves, when properly approximated, do regain their histologic structure and their function. There are three leading purposes in the surgery of the peripheral nerves. We operate for the relief of pain, by section; for the repair of nerve injury, by suture and by anastomosis; and for the relief of palsy by nerve transplantation. Let us now consider in some detail these three topics and the sui'gical measures at our command. NEURITIS Neuritis is a common cause of the pain, for which we may be forced to cut a nerve. The term neuritis is generally taken to signify inflam- mation of a nerve. It is usually an inflammation of the endoneurium, perineurium, or epineurium, which, through thickening and swelling, constricts the axones. Perineuritis is the accepted term, and the disease in this form is generally confined to a single nerve-trunk. Multiple neuritis, a painful affection of many peripheral nerves, is a degenera- tion of the nerve-fibers themselves rather than an inflammation. Mul- tiple peripheral neuritis commonly runs a self-limited course, and does not especially concern the surgeon, who has to deal rather with " local- ized" or " simple" neuritis. Simple neuritis arises from nerve injuries, wound infections, callus- formations, the pressure of new-growths ; or it is due to such chemical poisons as alcohol and ether^ as well as to exposure to cold; or it may arise as the sequel of some general infectious disease. The damage to the nerve may be strictly localized or may spread along throughout the nerve's course. Although the inflammation is acute and violent at the outset, the active symptoms may subside quickly and be followed by a long-continued chronic course, with hyperplasia of the connective tissue, causing more or less destruction of nerve-fibers. 696 THE HEAD AND Sl'INE The symptoms of the patient vary greatly, but always there is marked perversion of function, ranging from hyperesthesia to com- plete anesthesia. The pain is often severe, — stabbing, boring, or shoot- ing,— and is in the course of the affected nerve. It is worse at night than in the day, and is aggravated by movements. Tenderness also develops along the course of the nerve. There is frequent numb- ness, with tingling and loss of tactile sensation. There may be weak- ness or even paralysis of the motor nerve-fibers, with preceding twitch- ings and spasms. Sometimes, if the neuritis ])e long continued, seiious secondary changes — structural and trophic — occur in the adjacent parts — mus- I'ifi. 442. — Xerve-stretching. cular atrophy; contractures; nail ridges with nail thickenings; an atrophic, glossy, thickened skin; alterations in the sweat-glands; herpes, ulcerations, and gangrene even. Perforating ulcer of the foot (mal perforans) may follow neuritis of the tibial nerves. There are changes too in the electric excitability of the nerves, and the reaction of degenera- tion results. As a rule, the prognosis in acute neuritis is good; and after months even we may look for recovery. As for treatment, the surgeon has slight concern for that until called upon by the neurologist, whose non-operative measures have NEURALGIA 697 failed; but in advanced cases especially— those cases characterized by trophic changes, by gangrene and ulceration— nerve-stretching has been of marked value. Indeed, certain surgeons have carried still further the principle of nerve-stretching, and have shown this measure to be of service in cases of varicose ulcer, Raynaud's disease, and many other neurotrophic conditions. The technic of nerve-stretching is simple : lay bare and isolate the nerve-trunk which supphes the affected part. Then take the nerve on your fingers and stretch it vigorously by pulling it up (Fig. 442) . One may put many pounds of pull upon a nerve-trunk without breaking it. Experimental researches show that the nerve is traumatized — axis-cylinders and myelin — and that degen- erative changes follow\ Gradually the later, regeneration takes place. Meantime we expect to see improvement in the lesions for which the nerve-stretching is employed. NEURALGIA Neuralgia is an inadequate term for which we have as yet found no substitute. It means pain in the course of a nerve. Neuritis may be the cause of the pain, or the cause may be some constitutional disease (gout, syphilis), or a local lesion like mastoiditis or a tumor; or there may be any one of a hundred similar causes. The neuritis causing a neuralgia may be Hmited and superficial, or it may involve the whole of a nerve-trunk and its associated gangha. ■ Neuralgic pains are fairly characteristic. They are sharp, stabbing, boring, or burning, of varying intensity, and occur in paroxysms. They may be mild, or they may be so persistent and excruciating as to tempt the victim to suicide. The pain may linger dully between the paroxysms, or it may disappear entirely. Its onset is uniform: it ap- pears at the accustomed spot and follows the accustomed course. Some- times it becomes diffused, to the confusion of the patient and the physician. Do not mistake the characteristic, localized pain of a neuralgia for those simulated, bastard pains of which the hysteric complains. Victims of serious neuralgias, if unrelieved, go on to a life of con- stant and hopeless distress, and become slaves to drug habits. ^ Then- general health becomes seriously impaired, and they fall victims in turn readily, and cheerfully often, to other chance diseases. We treat neuralgia by drugs, by hygiene, by hydrotherapy, by electricity, and similar measures, and in most cases we succeed in curing the ailment. Some few^ cases, how^ever, resist such endeavors, and we find ourselves driven to surgical operations. These operations include some of the most difficult and hazardous measures known to therapeu- tics. Let us take up in brief detail certain forms of neuralgia and their treatment by surgical means. Trigeminal neuralgia, or neuralgia of the fifth cranial nerve, is common, but the cases vary greatly in severity. The mild cases are easily cared for; the severe cases demand operations of the first magni- G98 THE HEAD AXD SPINE tude. Accordingly, we divide the disease into sundry types, and refer to these types as — (1) Neuralgia minor — a mild affection in which one branch only of the nerve is affected; (2) reflex neuralgia, or visceral referred pain; and (3) neuralgia major, or tic douloureux. Let us deal biiefly with those first two forms. Neuralgia minor occurs commonly in neurotic girls and young women, and may be due to a variety of debihtating causes. Any anemia is apt to be associated with this form of neuralgia or tic. The reflex neuralgias, on the other hand, are due to some true anatomic lesion — ulcer, tumor, carious teeth, astigmatism, ear disease, etc. — which gives rise to an irritation in the neighboring trifacial nerve. The syfnptoms of both neuralgia minor and reflex neuralgia (tri- geminal) are quite similar, and the leading symptom is pain — pain confined commonly to one branch of the nerve. The pain is usually intermittent; it follows the course of the nerve, and is associated with tenderness of the surrounding skin — tenderness which often remains after the actual neuralgic pain has subsided. Sometimes, but not commonly, the pain is felt in quite distant, unrelated parts. You will observe that these symptoms are not particularly definite; indeed, it is not possible generally to distinguish the symptoms of a neuralgia minor from the early symptoms of tic douloureux. We must, therefore, watch all these cases anxiously, with the thought of a graver neuralgia in mind. As for the treatment of the milder forms of trifacial neuralgia, we endeavor to remove the causative irritant — in nose, ear, or mouth, — and we seek to improve the patient's general condition by good hygiene, food, iron, quinin, electricity, and an open-air life; and most often we succeed. If we fail, we may be driven to a resection of the affected nerve, after the method of Thiersch, which I shall describe presently; or to the injection of alcohol into the nerve-tnjnk. So far, we have been considering relatively mild forms of trifacial pain. Let us turn to that most grievous and special form, tic doulou- reux. A well-established tic douloureux differs in many essentials from the milder forms of tic. It is not a disease of young women, but appears in both sexes, and in middle life or later. The victims frequently are the subjects of marked arteriosclerosis. At first changes of climate, weariness, overwork, or any other causes tending to depress the circula- tion may bring on attacks. The exact nature of the process, however, is unknown to us. As Cushing saj's, " Let us hope that some one with new histologic methods and possibly more extensive material may solve this pathologic riddle, for not until the lesion is known may we expect to discover its causal agent." ' In other words, we find no constant histologic lesion in these cases. Certain writers regard the disease as an ascending neuritis, beginning in the peripheral branches of the fifth cranial nerve. In any case the Gasserian ganglion eventu- ally becomes involved in degenerative changes, so that only its extir- ^ Harvey Cushing, Jour. Amer. Med. Assoc, April 8, 1905. NEURALGIA 699 pation or severance from its central connections suffice to put an end to the j)iitient's sufferings. Those sufferings are illustrated by a train of symptoms which are characteristic in their agony when once the disease is well established. At first, as I have said, one scarcely distinguishes this severe form of tic from the milder forms. Usually, the second or third divisions of the nerve are attacked primarily — more rarely the first division. The pain begins in brief paroxysms, darting along the course of the nerve, in the lips, the tongue, the nose. Gradually attacks become more frequent and more prolonged, agonizing in character, so that the sufferer groans or screams with the intensity of his distress. The slightest irritant may bring on the attack — a breath of air, a touch, an unexpected start. Natural sleep becomes almost impossible; and the victims are given to the constant use of opium, and may contemplate suicide even. Such symptoms as I have described should serve to establish the diag- nosis. The examiner will find, in addition, that tender points may be determined at the places where the nerves find exit from their bony canals. Moreover, there are notable vascular changes and trophic and secretory disturbances, with flushing of the face, congestion of the eyes, outpouring of tears and saliva, running of the nose, falling or whitening of the hair or beard, and local sensations of swelling or ful- ness. All these phenomena occur on one side of the face only. We have been accustomed to state that treatment is palliative and radical. As a matter of fact, palliative treatment is of little service and gives but temporary relief. Nowadays one thinks of radical treatment as consisting in some operation on the Gasserian ganglion, but that operation has a decided mortality except in the most ex- perienced hands, and lesser operations often prove of service — operations on the peripheral nerves themselves. If the disease be relatively recent, and if the pain be assuredly con- fined to one branch only of the nerve, the surgeon may advantageously extirpate a large part of that nerve, with the fairly assured hope that the patient's pain will be relieved for several months, if not for years. Putnam and Waterman found the relief after peripheral operations to last for some ten months. This estimate is probably too short, for the statistics of these observers were founded upon operations of the older type — on simple resections of the nerves. We know that these neuri- lemmic nerves regenerate rapidly. The resection of Thiersch, there- fore, is recognized as the proper operation to-day. Thiersch's method consists in cutting doTVTi upon the nerve, seizing it, and twisting out centrally as much of it as possible from its canal. One, two, or more inches may be removed in this way. The second and third divisions are best suited for this form of treatment. Let me warn the practitioner against assuming that the pain is due to carious teeth. We see patients who have had all their teeth extracted from one side of the jaw, in the vain belief that thus their pains might be abolished. Sundry injections into the nerve-sheaths and into the nerves have been found beneficial of recent years. The favorite injections are osmic 700 THE h?:ai) and spine acid and 70 per cent, alcohol (osmic acid, 1 cc. of a 1 per cent, solution ; alcohol, 1.5 cc), repeated injections may be required. Probably a degeneration of the nerve-trunk toward the ganglion results. Un- fortunately, this method seldom has produced a pernianont cure. A more or less persistent local anesthesia results from these peri- pheral operations, but the maneuvers are practically safe always. It seems scarcely necessary to describe in detail the method of seeking and resecting these nerves, except the second and third divi- sions. Every anatomist knows how the supra-orbital nerve emerges beneath the brow toward the inner angle of the orbit; while the infra- Fig. 443. — Neurectomy, trifacial. Second division — step 1 (adapted from Kocher). orbital nerve may be reached at the infra-orbital foramen, one centi- meter below the orbital margin, at the upper end of the canine fossa, and vertically below the supra-orbital notch. The second division sometimes is sought at a deeper level behind the antrum, and Kocher 's operation is a favorite method by which to reach it : The incision below the orbit is carried outward and downward to the zygoma. The foramen and nerve are thus exposed. Then, at the outer end of the incision, the surface of the malar bone is scraped bare and the bone is divided with a chisel so as to open the sphenomaxillary fissure and to remove the roof of the infra-orbital canal. This opens the antrum. The incision is then retracted upward so as to expose the frontomalar NEURALGIA 701 suture, and from here the chisel is carried downward, inward, and backward toward the posterior part of the sphenomaxiUaiy fissure, through the orbital plate of the sphenoid. The zygoma being divided, tlie malar bone is dislocated outward and upward, and the contents of the orbit are raised, when the infra-orbital nerve may be followed back to the foramen rotundum, where the nerve is seized and pulled out. The third division of the trigeminal nerve leaves the skull by way of the foramen ovale, and divides into anterior and posterior branches. The posterior branch is sensory and in turn divides into the auriculo- Fig. 444. — Neurectomy, trifacial. Second division — step 2 (adapted from Kocher). temporal, the lingual, and the inferior dental. The ling-ual and inferior dental are most commonly concerned in tic, and their excision is part of one operation which Binnie admirably describes somewhat as follows : Begin the incision at the middle of the zygoma and carry the cut back- ward and downward to a point just below the tragus; then continue along the posterior margin of the jaw to its angle, and follow the hori- zontal ramus for about an inch. This cut is a skin cut, and should not involve the facial nerve, Steno's duct, or the parotid gland. Now make a transverse incision below and parallel to Steno's duct down upon the bone, striking the ramus about quarter of an inch below the sigmoid notch. Expose thoroughly the bone and trephine it through 702 THE HEAD AND SPINE and through. Then, with rongeur forceps, gnaw away the bone between the trephine opening and the notch. Now retract foi-ward the temporal muscle, remove obstructing particles of fat, expose the external ptery- goid, and retract it upward, when the lingual and inferior dental nerves will appear lying upon the internal pterygoid muscle. Secure each nerve with a suture, draw it down, trace the nerves up to the fcu-amen ovale, and divide them there. Then drag out by torsion their peripheral portions. Such are the best accepted methods of operating upon the peri- pheral parts of the trifacial nerve. After all is said, however, we must remember that these operations frequently do little more than palliate. Fig. 445. — Neurectomy, trifacial. Third divi.'^ion (adapted from Kocher). and that the truly radical operation must be directed to the (iasserian ganglion. The literature of Gasserian ganglion operations is now enormous, and the names of several well-known neurologic surgeons are associ- ated with the subject. We may not refer in general terms even to the different methods advocated and the various technics employed. Suf- fice it to say that surgeons have reached the ganglion by operating from above and from below — by the high temporal, the median direct, and the low pterygoid routes, and that with these routes are associated the names of Rose and Andrews, of Hartley and Krause, and of Cushing.' I am convinced that Harvey Cushing's method is admirably satisfac- tory, for it preserves the nerve-supply to the brow, avoids the middle ^ Binnie gives an admirable brief description of these operations in the third edition of his Manual of Operative Surgery, 1907. NEURALGIA 703 meningeal artoiy, and exposes the ganglion by the most direct route. Cushing's operation upon the Gasserian ganglion is step by step as follows: the field of operation about the ear is shaved, for the purpose of the surgeon is to seek the base of the skull through the temporal muscle. A slightly curved incision with convexity upward is made almost entirely behind the hair margin. To quote Cushing: " The skin- flap is reflected downward and forward by blunt dissection The temporal fascia thus exposed is incised in a line concentric with the skin incision and likewise reflected. The zygoma, which has thus been brought into view at the lower angle of the wound, is then shelled out of its periosteal sheath, not as formerl}' described, by making an Fig. 446. — Cushing's method of reaching the Gasserian gangUon (Cushing). incision along its external surface, but by crowding foi'W'ard its cover- ing en masse. The exposed fibers of the temporal muscle may then be divided as usual, and the muscle scraped away with a periosteal elevator as far dovm as the base of the skull. In order satisfactorilj' to expose the skull, a little deeper retraction of the flap is necessary than by the older method. With the soft parts and zygoma retracted dowTiward, the surgeon opens the skull with chisel or gouge at the lowest possible point, and enlarges the opening until it measures about 1^ inches. The middle meningeal arteiy lies on the dura and runs obliquely across the opening in the skull. Lift the dura with the arteiy from the base of the skull and dissect it cautiously away with a blunt instniment until you reach the foramen ovale. Then retract cautiously with a pliable ro4 THE HEAD AND SPINE spatula the cerebral structures. The surgeon himsel' should hold the retractor. The inferior maxillary nerve now serves as a guide from the foramen ovale to the ganglion ; split the sheath of the ganglion (the outer layer of the dura) and expose its upper surface. A^'orking still with a blunt dissector, isolate the ganglion and its sensory root. Then, with a blunt hook, pick up the sensory root, seize it with a hemo- 0»Ji«a. iy\«ivrS«».^o<«»i«. M _ r J OTCK -.._A>-^ ,/.,. f^ 'Vt»V*\'iAgJJ//M/^JJJ/J//j/i of a peripheral end regeneration. Other methods have been attempted, but with limited success. Nerve transplantation— the insertion of a bit of foreign nerve into the gap— has been advocated. Ballance and Stewart point out that the inserted nerve does not itself regenerate, but serves as a trellis for the training of the new down-shooting fibers. This operation has proved of small value. In the same way a trellis of catgut between the nerve- ends has been tried with small effect, and a tubular trellis (hollow bone tube) has served no purpose. In certain desperate cases some surgeons have resected the long bones themselves in order to allow of proper nerve approximation. Nerve anastomosis, how- ever, gives the greatest promise for the regeneration of damaged nerves, and the brilliant work of Gushing, Frazier, Spiller, and van Kaathoven in these Hnes seems full of promise. The mechanical principle of the operation is easy. A por- tion of a sound nerve, lying in the neighborhood of its damaged fellow, is trans- planted into the peripheral damaged end. The accom- panying figures, taken from Woolsey's article, illustrate admirably the purpose and technic of this operation. We shall have occasion in subsequent paragraphs to study briefly some of the more important nerve anas- tomoses. Neuromata, especially painful nerve tumors. B - ,^.,^,u^^m^!!A^.MWm't() Fig. 452. — Various modes of anastomosis: A, Represents the imaffected nerve, B, the affected nerve (Spiller, Frazier, and van Kaathoven). 'amputation neuromata," are extremely True neuromata are rare and small. Neuro- fihromata are common enough and reach a considerable size— as large, perhaps, as a small peanut. The amputation neuroma is properly a neurofibroma. When the nerve is severed in the amputation, its inherent force of regeneration stimulates often a rapid development of this small tumor, at the nerve's cut end especially, when the nerve-end lies in an irritative cicatrix. The common maneuver of pulling the nerve well do^Ti so as to cut it high by no means does away with the possibil- 710 THE HEAD AND SPINE ity of the neuroma's occurrence. These neuromata cause a constant, nagging, burning pain. Tliey prevent the weaiing of an artificial Hmb, and make the cripple wretched. Kecently we have been able to do away with these amputation neuromata through an opei-ation which leaves no nerve-ends. We take the nerve-ends in the amputation stump and suture them to each other. This is a primary suture and is followed by a prompt union with each other of the central nerve- stumps. The treatment of the neuromata themselves is simple enough, though the results are not always entirely satisfactory. Nerve-end neuromata should be excised, and the nerve-stumps should be so placed as to be free from irritation by the cicatrizing of the wound. This may be accomplished by laying the nerve smoothly in fascial jjlanes, or by wrapping it in Cargile membrane. Best of all is the practice of drawing out the refreshed nerve-ends and stitching them to each other in the fashion of an end-to-end anasto- mosis, as described in the last para- graph. By this maneuver all nerve- ends are eliminated so that the ordinary amputation neuroma finds no lodgment. When the neuroma lies upon the nerve-sheath in the course of the nerve, and not at its end, the little tumor may readily be shelled out. In all these operations on nerves the surgeon must observe careful hemostasis, and must enjoin absolute rest of the part for at least two weeks. The results of these operations are good, as a rule. Wounds and injuries of nerves occur frequently and are of im- portance only as they concern the subsequent function of the parts supplied by the nerve. When the nerve is but partially severed, reunion may take place without special treatment, provided the wound be kept free from infection. Lacerations of nerves are of manifold character and significance, and subsequent degenerations of the peri- pheral ends of the nerve may occasion a great variety of symptoms. No man may say at once from the symptoms observed how extensively a nerve is injured. It is well, therefore, always to expose the suspected nerve and to examine its condition. A laceration, a parently trifling, may lead to extensive changes within the nerve substance and in the sheath of Schwann, with a resulting soar formation completely blocking the nerve. Or a nerve apparently little damaged, but lying in a field of lacerated tissue, ma}- become nipped and thrown out of action by a resulting extensive cicatrix. For all such reasons, suspicion of nerve damage imposes upon us careful exploration and investigation. We must clear away the blood-clot ; must place the nerve as far as pos- Fig. 45.3. — Nerve anastomosis in stump. A diagram showing cross-sec- tion through lower third of the right leg, the nerves Ijeing enlarged to show sutures. OPERATIONS UPON THE NERVES 711 sible from damaged bone; must repair obvious gross lesions in the ner\'e ; must strip off carefully extraneous tissue, and replace the nerve, preferabh' wrapped in Cargile membrane, in a bed which shall admit of ready healing without undue external pressure. Be it remembered always that severed nerves, under favorable conditions, unite promptly, though a restoration of function will be many weeks delayed. Primary Fig. 454. — Illustrating method of spinofacial anastomosis (Harvey Gushing). suture of damaged nerves gives a far better prognosis for anatomic and functional restoration than does late suture, though recent experience teaches that late suture, even after the lapse of two or more years, sometimes ma}' be followed b}' excellent anatomic repair and functional improvement in the parts supplied by it. Nerve anastomosis and nerve-grafting are coming to occupy an important place in nerve surgery — for paralyses and to relieve spasm. 712 THE HEAD AND SPINE Paralysis of the facial nerve is a not uncommon condition and may- be the result of various operations and injuries. It may follow disease of the petrous bone and of the middle ear. It may result from operations upon the parotid gland and from operations on the neck just below the ear, as well as from fractures at the base of the skull. Rarely it may be possible to secure the divided ends of the facial nerve, and to unite them by direct suture, but more conmionly the surgeon is unable to find the proximal portion of the nerve, so that a restoration of facial function seems impossible. In such a case, as numerous investigators have demonstrated, one may graft into the distal portion of the facial nerve an active and functionating nerve in its neighborhood. The spinal accessor}^ and the hypoglossal nerves have been used for this anastomosis. While some operators claim special advantages for the use of the one nerve or the other, it has seemed to me that the spinal accessory nerve is subject to fewer disadvantages than is the hypo- glossal nerve, w'hen so treated. The spinal accessory nerve normally supplies structures whose loss of function is of no particular imi^or- tance, and every surgeon knows from his experience in operating for spas- modic torticollis that section of the spinal accessor}' nerve rarely results in a permanent paralysis of the mus- cles supplied by that nerve. Gush- ing especially advocates the spino- facial anastomosis, and I have repro- duced here his own interesting sketch which illustrates the proce- dure (Fig. 454). The operation is not easy. The nerves involved are small, and their suturing demands painstaking care. If the operation is properly done, however, a grad- ual return of facial function is seen, so that in the course of months little deformity remains. Facial spasm or convulsive tic is another condition which may be cured by the spinofacial anastomosis. In these cases, however, the operation must be regarded as a last resort. Few patients are willing to submit to the possibly complete facial paralysis which results if the anastomosis fails; while convulsive tic may often be relieved by some operation for disease of the teeth, eyes, nose, stomach, uterus, etc., inasmuch as the tic not infrequently is of a reflex character. To find the spinal accessory: Make an incision 3 inches long from the mastoid process downward along the anterior border of the stemo- mastoid muscle. Draw the muscle backward. Plunge the finger into the wound and feel the transverse process of the atlas, which is covered Fig. 455. — Facial paralysis — .six weeks after injurj'. Effort to close eye (Harvey Cushing). OPERATIONS UPON THE NERVES 713 by the digastric muscle. The digastric is the guide to the nerve, which passes between the bony process and the muscle, emerging at the lower edge of the digastric and passing to the sternomastoid. The inexperienced operator will always be surprised to find that the nerve lies much higher than he had expected. Spasmodic torticollis, or wry-neck, frequently is due to an irrita- tion of the accessory nerve — an irritation usually of central origin. Division of the spinal accessory nerve may benefit the ailment, but must always be regarded as an experimental operation. Often the muscular branches of the cervical nerves must be divided also. Keen's well-known operation involves paralyzing the large posterior root of the neck muscles through the section of the first, second, and third cervical nerves. The largest of these nerves is the occipitalis major, which first should be found and resected. It is a landmark which serves to identify the others. The steps of the operation are these : Make a four-inch incision transversely across the neck, starting three- fourths of an inch below the lobule of the ear. Sever the trapezius muscle. Raise the trapezius and isolate the occipitalis major, whose level is about half an inch below the level of the skin incision. Care- fully cut through the complexus, following the nerve in its course through that muscle. By this dissection one finds the nerve's bifurca- tion from the second cervical, and should excise a long piece from both nerves. Then search for and resect the first cervical, which lies deep in the wound above the second. One finds it by outlining the suboccipital triangle, bounded by the two oblique muscles and the rectus capitis posticus major. Search for and resect the external branch of the posterior division of the third cervical, which lies about one inch below the second, already cut. The surgeon may then reunite the muscles in order to obviate a needless deformity. After any opera- tion upon the nerves of the neck involved in spasmodic torticollis accurate wound healing must be sought through perfect hemostasis, approximation of the cut surfaces, and many weeks of immobilization and support by a Thomas collar or some similar apparatus. Incidentally, one observes, as a matter of no slight importance, that the relief or cure of spasmodic torticollis sometimes is secured by other than operative measures — by long-continued immobilization with ap- propriate apparatus. The phrenic and pneumogastric nerves sometimes may be subject to surgical operations — operations following nerve injuries from wounds of violence or from operations. Injury of one phrenic nerve paralyzes half the diaphragm, so that the repair of the injured nerve should be sought, though its reunion is not absolutely essential to life. This nerve is the most important branch of the cervical plexus, and lies upon the scalenus anticus muscle, where it may easily be found. Division of the pneumogastric (vagus) nerve on one side only causes no marked change in the pulse-rate, the respiration, or the digestive organs, but it does result in a paralysis of the vocal cord on that side. It may be possible successfully to suture the vagus. 714 THE HEAD AND SPIXE The brachial plexus frcfiuently is the site of serious damage, either from traumatism at birth or, more commonly in men, from heavy crushing injuries. The resulting paralyses must be studied carefully by a neurologic expert, for it is extremely difficult to determine readily the site of the laceration hi the complex anastomotic mechanism. The accompanying figures, taken from Woolsey's article, illustrate this anastomosis. Operators have attempted to repair these damaged nerves, but with varying and uncertain results. The obvious indication is to cut down upon the plexus through a long incision in the neck, and thoroughly and carefully to expose the injured structures. Rarely is Fig. l."»(i.— Dissection of the operative field in brachial birth palsy (Clark, Taylor, and Prout): A, Scalenus anticus muscle; B, phrenic nerve; C, internal jugular vein; D, transversalis colli artery, divided; E, seventh cervical root; F, omo- hyoid muscle; G, fifth cervical root; H, scalenus medius muscle; I, sixth cervical root; J, transversalis colli artery; K, suprascapular nerve; L, nerve to subclavian muscle; M, clavicle; N, nerve to scalenus anticus muscle (Woolsey in Keen's Surgery). it possible directly to unite in their proper relations the severed nerves. The construction of new and complicated anastomoses may be impera- tive. The functional results depend upon two factors: the accuracy of the wound healing and the ability of the patient to coordinate in the presence of the strange new nerve-relationships established. This last difficulty, however, is not peculiar to nerve anastomoses in this region, but is true of all nerve anastomoses. The various terminal nerves of the brachial plexus are subject to their own injuries likewise, and as they control the complex movements of the arm and hand, their damage is of vital importance to all men. It is needless here to take up in detail these subjects further than to remind OPERATIONS UPOX THE NERVES 715 the reader of two or three of the more important injuries to the nerves of the arm. Fracture of the humerus or an extensive wound of the upper arm may destroy the vmsculospiral nerve, when the characteristic wrist- drop ensues. The uhiar nerve may be damaged or destroyed through a fracture about the elbow-joint. There results the so-called " claw-hand," due p J / ■ K // . L M p. :' N £ V. i. y^^^^^i^) _ 0 ''"•: ...Q ^ — ^%<*S:^ R Uc *- \ Kr ■^^^ S 1 ^^^ ^^^iJL ■* '*4 fe^-^^' X u Fig 457 —Dissection of the operative field in brachial birth palsy (Clark, Taylor, and Prout)- A, Phrenic nerve; B, scalenus anticus muscle; C, internal jugular vem; D transversaHs coUi artery; E, omohyoid muscle divided; F, suprascapular artery divided- G, eighth cervical and first dorsal roots; H, external anterior thoracic nen^e; I subclavian artery; J, fifth cervical root; K, sixth cervical root; L, scalenus medius muscle- M nerve to scalenus anticus muscle; N, suprascapular ner^^e ; 0,transver- salis co'm artery; P, seventh cervical root; Q, omohyoid muscle, divided; E, supra- scapular artery; S, clavicle and subclavius muscle, divided and retracted; T deltoid, pectorahs minor, pectorafis major (muscles); U, nerve to subclavius muscle (Woolsey in Keen's Surgery) . to paralysis of the flexors in the proximal phalanges, except of the thumb. There is an associated cutaneous anesthesia which varies on account of the uncertain nerve anastomoses which may exist. The median nerve supplies those flexor muscles of the forearm and hand not supplied by the ulnar. Damage to the median nerve causes loss of flexion of the second phalanges of all the fingers, and of the third phalanges of the forefinger and middle finger, with loss of flexion, 716 THE HEAD AND SPINE abduction and opposition of the thumb, so that the thumb lies in exten- sion, adducted against the forefinger — the so-called " ape-hand." Pro- nation of the forearm is lost and the flexion of the wrist is weak. Injuries to these nerves result, however, in curiously uncertain phenomena. I have here described the characteristic phenomena, but immediate suture after damage may in certain cases cause a variation in the nature of these paralyses, greatly to the confusion of the examiner. In case continued doubt of the nature of the injury exists, the surgeon may justifiably cut down upon the nerve and ascertain its exact condi- tion. There are sundry other peripheral nerves which the surgeon may have occasionally to search out and operate upon in various ways. The intercostal nerves may be the subject of a neuralgia so extreme— from traumatism or in the course of a zoster — that their stretching or resection seems wise. In order to expose these nerves make an incision parallel with the spin- ous processes and two inches from them. Expose the intercostal muscles and divide them near the lower border of the ribs. ' ,58._wrist-drop from Thus you will brmg mto view the nerve musculospiral paralysis (Massa- lying below the vessels. The operation is chusetts General Hospital), an easy one. I have already spoken of stretching the sciatic nerve which lies behind the head of the femur at the point of election for stretching. The sciatic nerve rarely suffers traumatism from any cause, but may be involved in a tumor, and may be resected and sutured with expecta- tion of its restoration. In all cases of sciatica the surgeon should bear in mind the possibility of sacro-iliac disease or injury. The external popliteal or peroneal nerve, which winds around the fibula just below its head, is sometimes injured. This nerve sup- plies the anterior tibial group of muscles, which are frequently affected in anterior poliomyelitis. In such cases the surgeon will have an op- portunity to reinnervate the paralyzed muscles through anastomosis of the intact internal popliteal nerve with the distal portion of the peroneal. OPERATIONS UPON THE NERVES 717 The cervical sympathetic nerves occasionally are attacked by the surgeon for such conditions as glaucoma, exophthalmic goiter, epilepsy, and trifacial neuralgia. I see no reason to believe that this mode of treatment will remain in vogue for these diseases, but one should not overlook the technic of the operation. The maneuver is called by the extraordinary term " sympathectomy," and j-ou should perform it as follows: Make an incision from the mastoid process downward along the posterior border of the sternomastoid muscle to an inch below the clavicle, avoiding the spino-accessory nerve. Free the muscle, and draw it toward the median line, together with the vessels and nerves of the neck. Look for the sympathetic nerve in the middle of the wound, either on the posterior sheath of the vessels or on the vertebral column, where it lies in a special sheath. The books say you shall find it easily, but this depends upon your skill as an anatomist. In order to make sure of its identity, trace the nerve upward to its superior ganglion— then divide the ganglion fibers and tear away the nerve- Fig. 459. — Claw-hand. Griffin clutch of Duchenne (Fowler). tnmk which leads upward toward the skull. Next seek out the inferior thyroid artery through pulling it up from its bed by tension on the already freed sympathetic nerve w^hich surrounds it. Elevate the nerve and the artery together and separate them carefulh'. The next step is to remove the inferior ganglion — a difficult undertaking, since the ganglion lies deeply embedded at the base of the neck behind the clavicle, against the head and neck of the first rib, between the scalenus anticus and longus colli muscles, and just above the pleura. We use the already liberated tnmk of the nerve as a guide, and penetrate to the ganglion which is adherent to the vertebral artery, embracing it in a fine mesh- work. Then remove the ganglion. The reader will see that this is an operation not lightly to be undertaken, even by the skilled anatomist. The operation is tedious, somewhat bloody, not without danger, and most uncertain in its effects upon the offending organ. After the operation is over one must attend carefully to the dressings and the wound healing, for a septic infection deep in the neck is a serious matter. 718 THE HEAD AND Sl'INE The surgeon should repair the damaged structures carefully layer by htyer; he should employ deep drainage if there is persistent oozing; and finally he should support the neck carefully and immovably in a heavy dressing until all thinger of sepsis and hemorrhage be past. The reader will see, from his perusal of this chapter, that the sur- gery of the spine and peripheral nerves is reaching out in many new and unwonted directions. This is a field little cultivated as yet, of strange and unexpected possibilities, vigorously tilled of late by an increasing number of investigators. Even as one writes he feels that much which is hero said shortly must be revised. Like all new surgical fields, this is one of growing interest and of surpassing possibilities. PART VII MINOR SURGERY DISEASES OF STRUCTURE CHAPTER XXVI MINOR SURGERY^ The Examination and Study of Cases? Wounds ; Frac- tures; Local Infections? Massage About twenty years ago some one coined the phrase '' antiseptic conscience." I think it was Howard A. Kelly, of Baltimore. That phrase and the thought it contains were once essential, because twenty years ago most of the men who were doing the surgery of the world belonged to the generation which in its youth knew the old sepsis. To them the principles and practice of antiseptic surgery came haltingly and often imperfectly. They had, indeed, need to cultivate the anti- septic conscience; but they had conscience for many other things- great principles underlying good surgery, principles as important to- day as ever they were. One is impressed at times with the conviction that many of those sound, ancient principles latterly are being pushed back into a subordinate position. To-day a majority of the surgeons in active practice have grown up with the antiseptic idea. In the course of their development the antiseptic conscience has become part of their being. That intangible thing which we call surgical instinct includes and partakes of this same conscience. There is no danger of any man who has received his training in the past twenty years going far astray with that con- science to prompt him. Every source of surgical infection has been so thoroughly and universally studied that, with one or two exceptions, our aseptic technic is now perfect, or as near perfection as it is hkely soon to become. But there are those other general principles which were so miportant to the former generations. 1 This chapter is a reproduction, in large part, of a little book I published in 1903 Clinical Talks on Minor Surgery. That book was cast in the direct, personal lecture-room form— a form which may not be thought appropriate for a more tormai treatise on general surgery, but the " Chnical Talks" has been so kindly received that I am persuaded to embody it, with little change, m this volume. 719 720 MINOR SURGERY — DISEASES OF STRUCTURE If I name some of those principles, they seem commonplace enough, and men will say, perhaps, that they have them always in mind; but such is not by any means the conclusion of observers who watch the detail of work in our great hospitals. The most important lesson which a surgeon has to leani is to estimate the patient's general condition. I put that as essentially above any question of therapeutics. That matter of the general condition is a very large part of diagnosis. One has various routine questions which one asks in a perfunctory fashion: the patient's age, birthplace, resi- dence, occupation, family history, and previous condition of health, and in some sort one leams the answers — but those answers are not idle babble: the}^ have a very real bearing on the matter in hand. In a surgical clinic one is altogether too prone to assume that eveiy case is an operative one pure and simple, and one looks no further. This is one of the deplorable results of specialism gone mad. In the old days it was required of the surgeon that he have a good practical working knowledge of general medicine. Operations were a last resort; John Hunter and Liston told their classes that the knife was an oppro- brium, and should be used when all other means failed. Of course, that extreme view has long ceased to prevail — modified, first, by the introduction of anesthetics and later by the development of asepsis. Indeed, for long the pendulum was swinging the other way, when the knife was deemed the only reliable measure. Now, again, thanks to increased knowledge, we are appreciating that there are other resources. Every one of those data which the clinical clerk takes do-\^ai by rote may be of the greatest importance. Age may rule out man}- things, such as cancer, arteriosclerosis, and the like; the place of birth and the race may suggest tuberculosis or malaria, as may the residence. The other day I saw a case of anthrax of which the diagnosis was ren- dered probable by the patient's surroundings; there are numerous occupation diseases — lead-poisoning and " housemaid's-knee " will at once occur to the reader. That matter of family history or hereditary tendency is important, in spite of the new light we are constantly getting on the whole question of etiology; and especially the patient's previous condition of health is to be studied. Take, for example, a patient who illustrates in his o^^^l person many of the points w'e are considering. He is a young man. His age is twenty-three. He is of American parentage and of vigorous stock. He was born, reared, and now works in a town which is notorious for its unwholesome location, being low-lying, ill drained, and inadequately supplied with water. The young man is assistant to a sewer contractor, and spent most of one summer overseeing a gang of men engaged in laying drains. In September he became ill with typhoid fever, as appears from his phj'sician's statement and the story he himself tells. Typhoid was epidemic in his town. Recovering, after an illness of some two months, he returned to work. After an interval of six months he was seized with acute pain in the region of the right shoulder. The pain increased, and became severe — of a boring, throbbing, agoniz- THE EXAMINATION AND STUDY OF CASES 721 ing character. The patient looks hke a sick man. He is flushed, with a coated tongue, the bowels are constipated, the urine is scanty and high colored. The man supports his arm in his hand; he favors it, as we say, and is evidently in great suffering. On examining him we find his pulse to be bounding and rapid, with a rate of 116, and a blood-pressure recorded as 190 by the Riva-Rocci apparatus. AVhen we handle the arm we find some slight swelling and a sense of bogginess about the shoulder-joint; but the joint itself is not especially tender on pressure, and the patient seems to refer his pain rather to the head of the humerus. Here is a very definite picture. On the history alone one should be able to make a correct diagnosis. The man is obviously the victim of an acute infectious process. He has been for long exposed to un- sanitary conditions, and he has recently had typhoid fever. The leukocytosis in his case is 40,000, and the temperature 104° F. What are we to conclude from this collection of signs and symptoms? There are but two processes which suggest themselves at once — an acute infectious arthritis (articular rheumatism) and an acute osteo- myelitis. To distinguish between these two conditions is of the utmost importance. In the two diseases the signs and symptoms are in many respects identical, but we have two points as guides: the bone rather than the joint is the seat of pain, and the patient has recently had typhoid fever. We know that acute general infections are frequent precursors of osteomyelitis, and we are justified in concluding that we are dealing here with that process. A correct decision is urgent. Such a case should be admitted to the hospital at once, and the shaft of the humerus opened and drained, when doubtless he wiU recover with a useful arm. A few days' or even hours' delay might mean for him a systemic infection, septicemia, and death. To take up the thread of our main topic again: there is that inde- finable thing we call the patient's general condition. One cannot too soon begin to bear that thought constantly in mind. Sir Benjamin Brodie used to say that he could often make a diagnosis by the smell of the patient's bedroom. It is unnecessary for the modern student to know such shrewd tricks as that, but he must learn to put all senses into action. He goes to the clinic fresh from his laboratory studies. Hitherto he has learned the use of the sense of sight only, now he must cultivate his hearing, touch, and smell even, like old Sir Benjamin; and he must come gradually to appreciate that nebulous aura of physi- cal condition which every man, sick or well, carries with him. When to these things he adds those instruments of precision, the uses of which he has learned, there will be an accuracy and finalitj^ to his decisions which were impossible for the ancient men. One concludes from what I have said that a competent surgeon must be a very thoroughly equipped all-round man. Exactly that is my meaning. One must study general medicine as well as surgery, and must follow carefully both sets of clinics. There was a time, fifty years ago and less, when all surgeons were general practitioners. Then, 46 22 MINOR SUKGERY — DISEASES OF STRUCTURE /J^ with the development of specialties, came a natural antl proper narrow- ing of the surgeon's field. For years we devised new operations, we attacked organs previously regarded as inaccessible, we learned and perfected a new practice and a new technic. It has come about with this development of our branch of the art of medicine that many dis- eases as well as organs have become the surgeon's own, — his own in part at least, — diseases and organs with which he never thought to tamper a few j^ears ago. So again it is becoming apparent that he must be familiar with a great variety of processes which, a few years ago, con- cerned him little if at all. In that second stage of the surgeon's develop- ment he was often little more than a thorough anatomist and a clever handicraftsman. We have outgrown that stage. We now realize that tke surgeon must know and be ready to apply the principles of physi- ology, chemistry, pathology, and bacteriology, as well as those of anat- omy and physics. He deals with almost every known disease and with every organ of the body. He must be familiar with the stmcture and function of those organs, the nature of their disease processes, and the appropriate methods of treatment, if he is to put to their best and proper uses the therapeutic measures with which he is especially equipped. He must not stand idly by until his medical confrere says " cut." He must cut when the time comes, of course, but must use his own matured judgment to sustain the advice of his colleague. Before now, following the old blind method, the chest has been opened for empyema when no pus was there; the appendix has been removed when typhoid fever was the cause of the symptoms, and the gall-bladder has been opened for the cure of lumbricoid worms. I have even known a colleague to scoff at a surgeon who used a stethoscope, and to look upon a microscope as an instrument outside of his ken. A surgeon's duty is the treatment of disease by proper and recog- nized surgical measures; but he should have a sound knowledge of all disease as well, recognizing his ovm limitations; and while his medical colleague is at work with his proper investigations and remedies, the surgeon should stand by, waiting to be called upon for the employment of his own peculiar skill. Given then the particular case, such as that of the man with osteo- myelitis : One has looked the ground over, has ascertained the gravity of the general condition, and now turns his attention to the special lesion under consideration. That lesion is in the arm near the shoulder- joint; and without further doubt one makes the diagnosis and recom- mends appropriate treatment. But take another patient as a foil to the first. He, too, is a young man — not more than thirty-five; his previous condition of health is unimportant, and he, too, has a disease near the shoulder-joint. It is in the nature of a swelling or tumor, and he has had it for some fifteen years. It is a chronic process, therefore. When we see a swelling, there are two questions which should suggest themselves at once: Is this an inflammatory process or is it a neoplasm 9 For the purpose of practical exclusion i*un over rapidly the old formula which applies to acute inflammations — Is there pai7i, heat, redness, THE EXAMINATION AND STUDY OF CASES 723 sircJli7ig, and impairment of function? In this case all these are absent save swelling; moreover, this is a chronic process. Then call up the other familiar formula which applies to a swelling — What is its exact location, size, shape, color, consistency? One must have these two formuUr always in mind. This swelling has none of the characteristics of infianmiation, and the patient's general condition is excellent. There- fore it is probal^l}^ a neoplasm and of a benign type. It is situated just below the acromion process, over the middle of the deltoid muscle. It is about the size of a small orange; it is spheric and uniform in outline; its color does not differ from that of the surrounding .skin; it is soft, rather gelatinous to the touch, but it does not distinctly fluctuate. It is subcutaneous, movable, not adherent to the skin, and the adjacent glands show no metastasis. Observe carefully the method of approaching the patient and handling the Httle mass. See that he sits or stands at ease before you, with a good strong light upon him, while your own back is turned to the window. Gain his confidence by assuring him that you do not expect to hurt him. He will then sit relaxed and will not shrink or grow tense at your touch — an important desideratum. Now pass your extended palm gently over the tumor, once or twice. In that way you will gain a great deal of information, and if the parts are sensitive, you will give no pain. The tactus eruditus does not belong to the heavy- handed surgeon. One cannot too strongly urge upon the student the great advantage and importance of gentleness. Patients recognize it at once. The patient knows when he is being handled by a man who knoW'S his business. The reputation of being rough or brutal never helps a surgeon. See the thoughtless, inexpert man plunge at a painful, sensitive region as though he were kneading dough! One can teU the neophyte at once by his roughness. The gentle outspread palm and fingers of the examiner are extremely sensitive to tactile impressions and can be educated to a rare facility. It is seldom necessary to prod and poke with the finger-tips. Passing one's hand over the tumor in question, one readily defines its outline, its extent, its density, its mobility, and notes the absence of sensitiveness. Now one may pick it up in the finger-tips and de- termine, if necessary, its lack of fluctuation and the depth of its attach- ments. That is the whole story. We have the list of benign tumors in mind and, running over them, we see at once that this must be a fatty tumor or lipoma. After all, it makes Httle difference what we call it. The method of examination concerns us at present, and if one has learned to take a broad view of the case, to approach it without rush or flurry, and to observe accurately those few important details of w^hich I have written, the giving a name and the assigning treatment will naturally and readily follow\ 724 MINOR SURGERY — DISEASES OF STRUCTURE INCISED WOUNDS Twenty years ago Sampson Gamgee published in London one of the best books in English that is known to me on the treatment of wounds and fractures. After describing in some detail the pathologic conditions which arc met with in these phenomena, he goes on to lay down the cardinal principle of support for the injured part, and this he recognizes as the one essential in the therapeutics of traumatic surgery. We shall have much to say as to the meaning of that word " support." In the time of Gamgee's writing the word asepsis, in the modem sense, had hardly been invented; but it has now come not altogether justly to usurp the honors of surgical support; for in the consideration of all wounds, whether of the soft or hard parts, in which there has been any sort of disturbance of continuity, you should have constantly in mind that that severed continuity must prompth' be restored; that those restored parts must be absolutely immobilized and supported, and that this work must be done under aseptic conditions. Take a simple case in point. The patient is a tinsmith, thirty years old, sound and vigorous. About two hours ago, A\-hile at his work, he cut through the skin and fascia of his palm, leaving a clean, straight wound, extending about three inches across the hand. Let us see how we may apply our two principles, support and asepsis. We must regard what we have to do as a surgical operation. The whole field of the wound — and in this case the field is the man's hand — is sterilized, so far as may be — by a thorough scmbbing with soap and water, followed by immersion in chlorinated soda and wiping with cotton sponges dipped in 75 per cent, alcohol. The hand is then im- mersed for two minutes in an alcoholic solution of bichlorid of mercury, 1 : 3000. The hand and arm are then wrapped in a clean steamed towel, and the patient sits before the surgeon with his arm outstretched, palm upward, upon the table. Meanwhile the surgeon has cleaned his own hands with soap and water and alcohol, and has put on i-ubber gloves which have been sterilized by boiling. I have gone into this matter in some detail, because details in asepsis are the sine qua non of successful surgery. Let us now examine the wound. We must be sure always that no foreign substance remains in its depths, and in this case we find none. As the wound is held open, we see the extensive tear in the palmar fascia. One is scrupulous to close this, for by so doing we hasten the restoration of function. It is closed with three intermpted catgut stitches, and with the use of the curved needle rather than the straight one. There remains the skin-wound of the palm, which lies together without gaping. The severed edges are dusted with a simple drying powder, aristol; a bit of crepe lisse laid across and secured with collo- dion further supports them. One then applies a bit of absorbent cotton also held do^^•n with collodion about the edges, forming what we call the " cocoon dressing." INCISED WOrXDS 725 Now one would say that sufticient has been done to assure a prompt and sound healing by the "first intention"; but observe that the second only of our cardinal principles has been applied up to this point. A reasonably accurate asepsis has been provided; why is not that suf- ficient, and why do we go on to apply the first principle — support and immobihzation? A very simple experiment on one's own fingers will illustrate the reason. If I prick my finger sharply, tie an elastic band around it, and let it hang down for a few minutes, I find that the whole finger shortly will throb painfully, and the pricked wound will smart and ache. Now I remove the nibber band, place my hand upon the opposite shoulder, and hold it there steadily; I experience quickly relief and a sense of comfort. The series of phenomena which I have experienced are not dissimilar from what will occur in this man's wounded palm. Were we to leave his hand unprotected, except for the cotton and collodion, he would naturally swing it at his side. Al- most at once the process of repair will have begun — there will be the inevitable increased blood-supply in the wounded parts, a certain amount of exudation will go on, the venous circulation will be slightly impeded, and all these conditions will be accentuated by hypostasis if his hand hangs down; in other words, the reparative process will be interfered with. Hitherto surgeons have been able 'to devise no means of disinfecting thoroughly the skin. The epidermis may be scnibbed and treated with chemicals until it is fairly free from micro-organisms, but the corium cannot be touched by such methods, and in the corium normally there are to be found pathogenic organisms, mostly the Staphylococcus epidermidis albus. You must bear in mind, too, that in the aseptic operations of surgery we have three principal sources of infection to consider: First, the instruments; second, the dressings and suture materials; and, third, the skin, whether of patient or operator. At the present time we have advanced so far that we have eliminated the first two sources. Instniments properly boiled carry no organisms; dressings and suture materials properly steamed and prepared are sterile. So we come to the third source, the skin. Even that to a larger extent may be mled out, for we now wear aseptic gloves, — surgeons and all assistants, — so that we are left with the patient himself as the one most important carrier of possible infection; and after the most scrupu- lous care in preparation, the patient's skin must carry in its deep parts pathogenic organisms, as we have seen. One asks. Why do not these bacteria always produce sepsis? Because to do so they must be present in great numbers, or else they must fall upon suitable soil, or both. One need not review here the well-kno'U'n fact that in varj^ing degrees patients carry in their own tissues disease-resisting elements; suffice it only to remind the reader that organisms which will grow and multiply in and infect one man will fall harmless upon another; and here is the practical point, that in a great many cases, by appropriate treatment, one may help to bring nearer to immunit}', and may fortify the resisting powers of an individual patient. 726 MINOR SURGERY — DISEASES OF STRUCTURE So it is practically in the patient's own skin, and there chiefly, that we must look for a source of sepsis. What became of the organisms at the time our patient received his wound? Some of them were undoubtedly carried into the deeper parts, some of them still remain on the cut edges, and others will be foi'ced into the wound itself and into the general circulation during the earl}' hours of repair. Now this man's hand has been n^ieved of a large number of organisms by the antiseptics we have applied. We must strive to render the deep parts of the field infertile. No better medium exists for the growth of organisms than a stagnant or sluggish blood-sup}:»ly, and that condition exists to perfection \\-hen we leave the man's hand hanging at his side. So we place it high upon his chest and secure it in a sling. We have now provided for asepsis and elevation. It remains for us to secure surgical ini mobilization. If we leave the man's hand iniconfined except by the light, support- ing sling, there will be nothing to prevent his withdrawing it from the sling, and there will be nothing to prevent his using the hand and fingers, even if they be elevated. Here, again, one asks. What harm can possibly result from such use? We have conceived of an exudation essential to the healing process in the palm; we have conceived of an increased flow of blood to the part; we can further see how the support of the arm has improved the venous circulation, and it takes very little imagination to understand how the action of the muscles dragging, pulling, and contracting may well keep up an irritation W'hich, superadded to the other conditions, will permit of a bacterial activity and initiate a sepsis. These are simple conceptions, but they illvistrate a condition which, after all, is simple enough; again we come back to our point and say that the one thing left and needful for the repair of this man's wound is immobilization. Perfect immobilization, in the surgical sense, is far from being the simple thing one might suppose. It is not readily attained; and it cannot be attained without giving careful thought to the anatomy of the parts. Take the instance of the man's wounded hand. What are the important structures which go to make up the anatomy of the palm and adjacent parts? Obviously, they are the skin and fascia, the underlying tendons and muscles, and the bones. We cannot keep the wound in a state of surgical rest unless we immobilize the adjacent stmctures, and that means that we must tie up the muscles of the part. Those muscles are the extensors and flexors of the hand, and their origin is about the condyles of the humerus and in the forearm, a fact elemen- tary and obvious enough, but surpiisingly often overlooked. So we must bandage carefully and restrain the movements of the forearm. Observe now a point which we must emphasize repeatedly. Never apply for immobilization a bandage close to the skin or over a thin intervening pad. Leani always to use elastic covjpressioji. We cover the patient's hand and forearm with six or eight layers of sheet-wadding INCISED WOUNDS 727 — an elastic, very slightly absorbent material, which will not become caked and matted with perspiration. Between alternate layers of the wadding place four strips of moistened mill board — two laid straight down the arm and two twisted spirally about it. These harden as they dry, and lend an added stiffness and elasticity to the dressing. So far the' application looks cumbersome and unwieldy, but with this cotton roller we now carefully and snugly bind the whole into place. Pull the bandage tight, greatly diminishing the bulk of the dressing, so that when completed it appears to be of moderate proportions. If you handle the completed dressing you find that it is quite elastic to the touch, and that it exerts everywhere a perfectly equable compression. It controls absolutely the muscles ; no movement can go on underneath it, yet it is extremely comfortable. It is tight, but it does not constrict. By its firm contact everywhere with the underlying parts it moderates and controls the circulation, but it does not occlude it. Here we have illustrated on a large scale the principles of compression which one applies when he seizes and compresses gently and brings comfort to his sore thumb, which throbs and aches with the beginning of a " nm- round." Thus one sees employed the four remedies which one must learn to apply in the dressing of all wounds: asepsis, elevation, immo- bilization, and compression, and the last three imply swpporf — remedies which may be modified in degree often to suit special conditions — perhaps they are employed with oversciTipulous care in this particular case; but they are always important, always to be borne carefully in mind; to become as much a part of one's instinct and training as that antiseptic conscience of which we have heard tell. Consider next two cases which illustrate the results of proper and improper treatment. A lad received a ragged, four-inch wound of the wrist from falling on a broken bottle some ten days ago. The skin cut one sees, but more than that, the superficialis volse artery and one tendon of the flexor sublimis digitorum were severed. When brought to the hospital, about three hours after the accident, the boy's arm was found tied up tightly with a knotted handkerchief, — as a tourniquet, — the wound gaping and ugly looking, where cobwebs — a favorite domestic remedy — had been smeared over it, blood still oozing from the artery, and the whole hand livid, swollen, and painful. The patient was laid on the operating table, the handkerchief re- moved, the arm elevated in the air and supported by an assistant for about five minutes, when the bleeding was found to have ceased, the swelling to have subsided, and the hand to be normal looking and pain- less. Then the whole arm and hand were cleaned and disinfected — washed, scrubbed, and soaked, not dabbed at and mopped over with a futile corrosive sponge. The two ends of the cut vessel were secured and tied with catgut, the severed tendon was united by fine silk stitches, the skin-edges care- fully and accurately approximated with four silver wire points, — which I prefer in the case of these ragged cuts of the wrist, — and the hand and arm put up in the manner demonstrated in the case of the tin- 728 MINOR SURGERY — DISEASES OF STRUCTURE smith. In this case, of course, the wrist was secured in a position of slight flexion to reHeve tension on the severed tendon. After the first dressing the patient felt perfectly comfortable; his temperature was normal and his bodily functions undisturbed. Twice during this time an atlditional tight bandage was applied over the dressing, which had become somewhat loosened. The apparatus being removed, we observe the entire limb to be pale and shrunken. That is as it should be. The hand looks thin and normal; the fingers are flexible; the wound is a simjjle red line — not puffy, not tender, not painful. The old cocoon dressing shows a little dry, blood-stained exudate. One removes carefully the silver stitches which have admirably supported the irregular skin-edges, and the wound is found practically healed. Of course, there is more to the case. That tendon wound will be slow in healing, and the hand must be protected and supported for some weeks on that account, but so far as our simple incised wound is concerned, it need trouble us no more. The dressing was dry and it was infrequently renewed. Napoleon's famous surgeon, Baron Larrey, was the great exponent of that method a hun- dred years ago. Read what he says in his delightful " Memoirs" on the subject of infrequent dressings. Turn your attention to a man whose story is not so happy. He is a postman. Five days before we saw him he received a cut on the back of the left forearm, being struck by a piece of falling wintlow-giass. The cut was about six inches long. Only the skin, thick fascia, and some fibers of the muscles of the extensor group were cut. There was little bleeding. The wound was cleaned and covered in with the greatest care, but a supporting bandage and sling were omitted, at the man's request, as he said they would interfere with him and that he would be careful not to use his arm. On the sixth day he reports for the first time after five days of active running about, swinging the arm at his side. We see the state of his wovmd and compare it with that of the lad with the severed tendon. In the postman's arm is a distinctly reddened area, extending for an inch all about the cut, the edges of which are infected and slightly swollen. We remove one stitch and find it is followed by a drop of pus. The man says that the wound has ached for the past two days, and that he has felt "feverish" and uncomfortable. His temperature is 99.4° F. The arm has not the shrunken, cool, almost anemic look that we saw in the last case, but is distinctly warm and full. Fortu- nately, no great damage has been done as yet. By appropriate treat- ment the initial sepsis may be checked, but the man has delayed his convalescence by several days, and we have a series of troublesome dressings to occupy us. So much for the three cases of simple incised wounds. They have been striking types and have told their own story, yet one must qualify that story in a few words. AU incised wounds carefully cleaned and put up with compression and elevation do not heal promptly, nor do all the wounds, lacking that SIMPLE OR CLOSED FRACTURES 729 support, become septic. If there is any one thing true of surgical thcM'ai)euti('S, it is that there is in it no pkice for dogma. Beware of the surgeon or physician who says, thus and thus shall it be done and not othei-wise. Such precepts make of surgery an exact science, which it is not, and the men who presume to apply to it iron-clad rules have to change their dogma from year to year. But there are broad general principles which the student will find safer than dogma. Two of those broad principles we have studied — asepsis, rigid asepsis, must be the sheet-anchor in all surgical work; physiologic support, immobilization, compression, next after asepsis, are essential for the safe and prompt healing of the great majority of wounds. SIMPLE OR CLOSED FRACTURES Percival Pott fell down in a London street and broke his leg a hundred and thirty years ago. He got well and wrote about it, and since then surgeons have known more about fractures than they knew before. Pott's famous fracture marks an era in our annals. From that time to the present our knowledge of fractures has been growing more definite, until to-day, with x-ray plates for aid in diagnosis, there is small excuse for any surgeon's going far astray. Yet men, even the expert, do go astray. Probably there is no class of cases presented to us which is so easy of misapprehension, and in which the results of misapplied treatment are so deplorable. We shall not now consider fractures in detail, but glance at two or three simple cases and note the methods of handling them, of making the diagnosis, and applying a suitable treat- ment. We shall regard closed fractures only, or, as they are more com- monly called, simple fractures. The analogy between lesions of the soft parts and of bones is a close one. The processes of repair are not dissimilar, and the rules of treat- ment do not diverge greatly. But our analogy is incomplete in one important particular. In the case of severed soft parts union will take place though the apposition be imperfect, and though the united struc- tures themselves be dissimilar— with a delayed result, to be sure, and with more or less impairment of function : there we have nature, un- aided, working out her faulty solution of the problem. But in the case of a broken bone, our art must be carefully and constantly applied if the injured member is to be restored to any sort of usefulness. For example, take the case of a boy, sixteen years old, who, while running, fell against a curbstone and injured his forearm. We see him supporting the damaged limb with his hand and complaining bitterly of pain half-way between the elbow and the wrist. Let us proceed with our examination carefully and painlessly to him, so far as we can. In the first place, the patient's clothes are stripped off to the waist, thus allowing of easy inspection — an important point. In removing the various garments, slip off the coat-sleeve from the sound side first; then the injured arm can be uncovered without undue straining. Cut the shirt down the front and slip it off as you would a coat. 730 MINOR SURGERY — DISEASES OF STRUCTURE Allow both his arms to hang down, and observe any differences in them. We see that the affected arm hangs limp and motionless; the boy cannot raise it. It appears slightly swollen, and one may detect a slight backward bowing. So much for inspection. Then compare the two ai'ms by measurement. Observe that on the sound side the distance from the tip of the olecranon to the ulnar styloid is ten inches. On the affected side it is nine and one-quarter inches. Obviously, there is a shortening of the bones; that means frac- ture. Is it a fracture of one or both bones? Of both certainly; for if the ulna alone were broken, the radius would act as a splint and main- tain the length of the arm wdth little if any shortening. So we have concluded that we are dealing with a fracture of both bones of the forearm, and so far we have caused not the slightest pain. It remains to locate the exact seat of the fracture. Now it may be necessary to hurt the patient somewhat, but if we proceed cautiously, he will bear it well. It is best to employ an assistant — two assistants are even better. The patient sits with his arm extended upon a table. One assistant sup- ports the elbow firmly, the other holds steadily the lower part of the forearm, making gentle traction; for there are spasm and contraction of the bruised muscles. The examiner now runs his hand gently up and clown the arm and comes at once upon an area of thickening, about five inches above the wrist. That area is the seat of fracture. Grasp- ing the arm firmly above and below the injury, while the assistant continues to make traction, the surgeon molds the bones into position, reducing the overriding where the distal fragments have slipped over and behind the proximal. While so molding, the operator experiences that sensation of grating or "crepitus" of which we hear so much. While we keep up the traction observe that the arm has been brought back to the same measurement as its fellow. If the spasm had been very strong and reduction of the fracture impossible without causing great pain, we should have given the patient an anesthetic. We come now to the difficult question of the support and immo- bilization of fractures. As John Hunter said, "The first and great requisite for the restoration of injured parts is rest." Shall we employ our cotton rollers and mill-board strips with elastic compression? That certainly would give rest to the parts, and it has at times been used with success in these cases. If this were the fracture of but one bone, we should use that dressing. As a rule, however, its very elasticity renders it unsafe when we need extension or traction to keep the bones from overriding again. There are innumerable splint materials, from plain strips of wood to molded gutta-percha, wood fiber, felting, and plaster- of-Paris. The first of these, known among us as "splint wood," and the plaster-of-Paris are convenient and are in common use. I shall use splint wood in this case, as the arm will probably swell, and splints of splint wood can be removed easily and readjusted. There remain two other important points to consider before we apply the dressing. We can lay it dowTi as a safe general mle in dealing with all fractures of the long bones that the adjacent joints at either SIMPLE OR CLOSED FRACTURES 731 extremity nuist be immobilized, otherwise the phiy of the muscles will not be liekl in check, und with the movements of the joints there will be a constant displacement of fragments. Moreover, without immo- bilizing the joints the required extension cannot be maintained. In this case we must fix the elbow and the wrist. The second point is that with fractures of both bones of the forearm and the possible large resulting calluses which sometimes form, the position must be such as to keep the shaft of the radius as far as possible from that of the ulna, else all four wounded bone surfaces might become united in a common callus, and future rotation be impossible. In supination, wdth the palm turned upward, the shafts are well apart; in semipronation they are somewhat further apart; in extreme prona- tion they are thrown close together, and if there be extensive laceration of soft parts, it is possible even for the distal fragment of the radius to become united with the proximal fragment of the ulna. Applying Splints. — In the present case we have the arm held firmly in semipronation and proceed to apply the splints — a simple matter now. The splints of light, thin wood should be a quarter of an inch wider than the forearm. The posterior splint extends from three inches above the fracture to the metacarpophalangeal joints; the anterior splint from the same point of the forearm to the middle of the palm, and a large crescentic groove is cut out of its side to avoid pressure on the thenar eminence. The splints are carefully padded with six sheets of w^adding, with extra small pads on the anterior splint to conform to the contour of the wrist. Then an "internal angular" splint of molded tin is similarly prepared to support the elbow. WhUe the arm is held steadily by an assistant, who stands on the patient's- outer side, the surgeon applies these splints and fastens them firmly but not tightly in place by four-inch adhesive straps passed round one and a half times. There are three straps — one about the proximal end of the splints, one about the wrist, and one about the palm, em- bracing the posterior splint only. This last strap is very important, as by its firm pull on the posterior splint it keeps up traction. Then the elbow splint is applied with three straps — one at each end and one just below the bend of the elbow\ The whole we cover with a cotton roller, snugly put on. That is a fairly comfortable dressing, but one must still be on the lookout for trouble. Keep the patient in sight for half an hour, and see that there is no return of pain before he leaves the hospital. Increase of pain, throbbing pain, especially if the fingers become swollen or blue, means that splints are too tight. One must remove and reapply them. Then we must support the arm in a com- fortable sling before sending the patient out. If he goes from the hospital in pain, we may be certain that he will suffer greatly before morning, and the frequent swelling of the arm, against the immovable splints, may give rise to ugly skin sloughs. As for the after-treatment — that is not always easy; it calls often for the best judgment and, w-hen neglected, may lead to serious 732 MINOR SURGERY — DISEASES OF STRUCTURE deformity. Moreover, forearm fractures not uncommcnily result iu non-union, and against that we must guard. One advantage of the use of open splints is that they are easily removed for inspection of the wound. We shall ask the boy to return daily for three days. If we find the arm painless and the swelling not conspicuous, we shall have him wait until a week from the accident has elapsed before changing the splints. Another patient has a similar fracture ten days old. We see that on removing the bandage the position of the bones appears good, the swelling has subsided, and the plaster straps are a little loose. The splints are taken off, when a slight callus is felt over the seat of the frac- ture. The skin is shrunken and pale, and the elbow^ and wrist are moved with some pain and difficulty. Here is an opportunity, if we wish to help the union and hasten convalescence, to do a piece of work usually neglected, but work for which the patient will bless us. We shall call in a competent masseur, and have him manipulate the elbow, the wrist, and the tissues about the fracture for half an hour every day. The arm must be securely held on a firm cushion or on the padded table while the masseur is at work. He kneads the muscles about the joints, he loosens slight adhesions, he restores the stagnant lymphatic circula- tion, he stimulates the circulation of the whole arm, and by thus improv- ing the nutrition of the parts, he hastens the union of the broken bones. I have employed massage for years in such fracture cases as have come under my care, and am constantly impressed with its advantages — in the hastening of repair, in the early restoration of function, perhaps, best of all, in the sense of w^ell-being given at the time, and in the feeling of security and confidence so soon as the patient reaches the stage at which active movements begin to succeed these passive ones. Under the old-fashioned treatment the arm was like a prisoner confined for weeks in a dark, narrow cell, to emerge at the last, pale, timid, spiritless, broken down — who must wait weeks yet before his proper vigor returns to him. With massage you let in air and light upon your captive; his windows are throw^n open daily, and he is taken for a brisk walk, as it were, about the prison yard. At the end of his confinement he returns to the former life with his force but little abated and his zest sharpened for the work of the world. LACERATED VOUNDS Let us study a case, that of a teamster, forty years old, soimd and vigorous. Twelve hours before our inspection, while unloading his wagon, he let fall a heavy iron bar, the end of which struck his calf and inflicted a ragged triangular wound. Some six inches of skin were torn up, the muscles lacerated, and the head of the fibida exposed. The bleeding was inconsiderable. At the time, he wrapped an old hand- kerchief about the leg, passed a painful night, and entered the hospital in the morning. Fort)-five years ago, in the days of the Civil War, such an injury LACERATED WOUNDS 733 might eventually have led to amputation ; even now it is not without its clangers. Septic material has undoubtedly been carried deeply into the leg. The iron bar itself was unclean, and the man's well-worn, sweat-soaked working trousers were far from aseptic, while the skin of the leg itself is loaded with organisms. Two courses are open to us in such cases — to clean up the leg and the wound, apply wet antiseptic dressings, and look for a slow healing b}' granulation, or to bring the severed skin and soft parts back into place and try to obtain a prompt healing by primary union. "\A'e adopted the latter course, and through the application of our two great surgical principles — asepsis and physiologic rest — we looked for a good result. That pleasant old Frenchman, Le Dran, in 1735, used to tell his classes that in such cases as this he always tried for a primary union, because if that failed through catching cold in the wound, he could take out his stitches and expect a second intention. I suppose that phrase "catching cold" is as old as Hippocrates. Of course, Le Dran's reasoning still holds good, though to us now such a method seems a half-hearted way to approach a surgical problem. In the case of the teamster we begin our proceedings by etherizing the patient. It is cniel as well as stupid to attempt a painful and extensive dressing without an anesthetic. The leg is shaved and thoroughly scrubbed, then the wound is mopped out with dioxid of hydrogen, followed by bichlorid alcohol 1 : 3000. Bits of torn cloth- ing and dirt are picked out first. If we look carefully, we see that the fragments of torn muscle are viable; they bleed easily and can be reunited. The sewing of them properly is important for two reasons — because if left loosely flapping, no good muscle union will result and the leg will by so much be weakened, and because the drawing of them together fills up the cavity between and prevents the collection of blood where it would serve as a culture-medium in that '' dead space." Let me quote Le Dran, who said that in a deep wound in which the muscles are divided obliquety the deep stitches should be passed so as to i-un parallel with the muscle-fibers, and not obliquely, as would be natural in sewing up an incised wound. Having closed in the deep parts, we lead into the bottom of the wound a single strip of absorbent tape or wick, placing it gently and loosely, that it may act as a drain and not as a cork. The skin is now dra-v\Ti over the restored muscle, and stitched into place with a half- dozen silver or silkworm-gTit stitches. The leg is again washed with bichlorid alcohol and elevated in the air, thoroughly to drain the veins and promote freer circulation. Asepsis is complete; then comes the second step — support and immobilization. In this case we bind the muscles from the toes to the middle of the thigh; — first, covering the wound with a handful of loose absorbent gauze, to act as a drain and reservoir for the inevitable discharges, then firmty and snugly apph-ing our mill-board and wadding rollers. One sees how securely they hold the leg and how the knee and ankle both are immobilized without discomfort. 734 MINOR SURGERY — DISEASES OF STRUCTURE We cannot put the leg in an ordinary sling as we did the arm, but we can keep it elevated, and so add greatly to the jjatient's (-(jnifort. Of course, this man lies in bed for a few tlays. \\'e swing a gauze ham- mock from a rod which is stretched from the headboard to the foot of his bed. In this hammock the whole leg rests, from foot to hip. That is a most satisfactory, comforting device. It gives us our required support and elevation, and as it swings, it allows the patient to shift himself about and even turn in bed without disturbing the wounded leg; for as the body moves, the hammock swings, but the leg remains rela- tively at rest. On the second day the wick is removed under the strictest aseptic precautions; the leg is bound up again, and at the end of a week we show it soundly healed. Ambroise Pare wrote to his petit maistre in 1580: ' M. le Prince de la Roche-sur-Yon, who clearly loved the king of Navarre, drew me aside and asked if the wound were mortal. I told him Yes, because all woutids of great joints, and especially contused wounds, were mortal"; and in the sequel the King of Navarre died. Ten years ago, a friend of mine, while leading a landing party on the coast of Cuba, was shot through the elbow by a Mauser rifle. The wound was properly dressed and supported, and in the course of a month the use of the arm was restored perfectly. A patient who illustrates our subject — wounds of joints — is an Italian recently in a street row. He came out of it with an ugly, ragged cut, which nearly severed the insertion of the triceps tendon and laid open freely the elbow- joint from behind. As we hold the edges of the wound apart, we see the articulating surface of the olecranon and a bit of the internal condyle. Let us attempt to save the arm with a useful joint. The man is etherized, the arm carefully disinfected, and while an assistant holds the wound open, we wipe out the joint with little gauze sponges dipped in bichlorid alcohol, and then douche it thoroughly with sterilized water, taking pains all the time not to bruise or othei'wise injure the serosa, lest we set up an adhesive inflammation which might lead to ankylosis. Next, with fine catgut stitches, we sew up the rent in the capsule and unite accurately the severed ends of the triceps muscle. In sewing up the capsule take special pains to evert the edges, that no rough surface be turned into the joint to cause mechanical irritation. Then the skin-wound is brought together, and covered in with gauze pads. In the final binding of this arm we have to meet a problem which differs from most of those encountered in the upper extremity. We cannot, flex the elbow and support it in a sling, for by so doing we should run the risk of tearing the freshly se-^-n triceps. So the arm is put up in extreme extension, with our mill-board strips to preserve fixation, and plenty of cotton rollers to give elasticity and comfortable, even com- pression. This man is not allowed to go out with his arm swinging at his side. The wound is a serious one, and demands great care for a few days. LACERATED WOUNDS 735 He is put to bed aiul the nrm kept at an angle of 45 degrees, either on pillows or, as 1 prefer, in our gauze hammock. Not long ago 1 was asked by a physician in a neighboring town to see a patient, with a view to an amputation. The man was suffering from a wound somewhat similar to this last one, but in the knee-joint. He had received his injury ten days previously. Not realizing its gravity, he had neglected to call a physician, contenting himself with lying in bed and keeping the knee wet with applications of " listerine." My friend had seen him only a few hours before my visit. I found the patient to be a middle-aged, sturdy sea-captain. He was lying in bed and was evidently in pain. There was a punctured wound on the outer side of his right knee-joint. The edges were gray and sloughy looking, and a thin pus could be pressed out through the opening. A culture from this discharge showed later a staphylococcus infection. The whole knee was red, boggy, tender, and swollen, the dimples on either side of the patella being obliterated, and the synovial pouch distended three fingers' breadths above the patella. The man's tem- perature that morning was 100° F., and his pulse 110; his face was flushed, appetite nil, and the picture that of a very sick man. There was present a leukocytosis of 26,000. I agreed with my consultant that an amputation must be considered, but advised making an attempt first to save the leg. The patient was etherized, the leg cleaned up, and the wound enlarged so as to admit of thorough exploration of the joint. The serosa was seen to be deeply injected, and several ounces of pus were evacuated, but the integrity of the joint apparently was not yet affected. The whole interior surface was carefully and laboriously mopped with dioxicl of hydrogen and douched with sterilized water. Counteropenings on the inner side of the patella and in the popliteal space were made for drainage and tapes were inserted in all the wounds. Then a large absorbent pad was placed about the knee, the leg thoroughly wrapped and supported after our familiar fashion — the dressing extending from the toes to the groin. The leg was slung in a hammock, \ grain of morphin hypo- dermically was administered, and the patient was left with careful directions that his bowels be kept open by salines and his strength supported by frequent liquid nourishment and a drink of Scotch whisky three times a day. Of course, in this case we did not look for the restoration of a sound, flexible knee-joint. The best outcome to be expected was the saving of the leg with a stiff knee. I did not hear of that man again for seven days, when my friend again asked me to see him and to do the dressing. The picture he presented was most refreshing. Except for pallor and feebleness, all evidence of sickness had left the patient and he received me with the comfortable assurance that he was well. During the week the wicks had been changed three times by his attendant, and I re- moved them for good and all. On taking off the dressing I found the leg pale and the skin shriveled in appearance, with the familiar contour of the joint restored. There was slight though rather painful motion. 736 MINOR SURGERY— DISEASES OF STRUCTURE which I did not encourage. The two wounds were granulating well. Eventually the patient recovered with joint motion of 20 degrees. This was a gratifying result. I attribute it to the man's remarkably good general condition, supplemented by the strict enforcement of our cardinal rules — asepsis and support. Let us return for one moment to that other man — the tinsmith, whose cut hand we sewed up. It was not seen for ten days, though he reported to assure us of his comfort and the absence of pain. Freed of its dressings, the wound is found to have healed per primam, as was to be expected. We confine the hand in a light bandage for five or six days longer and then send the man back to his work. All these are good results only, but one must not conclude from them that surgeons are wizards. Bad results — unavoidably bad results — come often enough, and we see a plenty. For the present, we are illus- trating the constant saying of Ambroise Pare, '' I dressed him, and God healed him." COMPOUND (OPEN) FRACTURES In connection with the subject of lacerated wounds we must con- sider compound fractures. They are no more than special varieties of lacerated wounds. These fractures were regarded with extreme alarm in the old days, and are still not to be treated cavalierly. Chelius, of Heidelberg, wrote in 1821 that " the inflammation is always \ery great and requires strict antiphlogistic treatment, blood-letting, leeches, cold applications, and opium," and that mortification and delirium tremens may occur especi- ally in old people. " If sleep do not take place, death is the consequence. On dissection frequently there is exudation on the arachnoid, pus in the joints and in the sheaths of the tendons." All of which, of course, re- sults from the fact that we have to deal with a lacerated and easily infected wound, which involves a structure of low vitality. Our effort, therefore, must always be to substitute a closed fracture for an open one, and then to treat the damaged bone on the ordinary principles. Here again we come back to that matter of rigid asepsis and immobilization, the latter being of great importance, for broken bones which are not held strictly at rest keep up an irritation of the wounded soft parts, delay healing, favor the continued outpouring of a serohemorrhagic exudate, and so provide a medium for the develop- ment of micro-organisms. The young woman whose case we consider first was jostled against a moving cart, and her arm, thrust between the spokes of the wheel, was severely mangled. On being brought to the hospital shortly after- ward, it was found that both bones of the forearm were broken in the middle third and that the two upper fragments were protniding through a hole in the skin on the dorsum. The house surgeon who dressed the case very properly was not content with mere reduction of the fracture, but with pains and elaboration restored the continuity of all the severed COMPOUND (open) FRACTURES 737 parts. The wound was enlarged by free incisions, all bleeding com- pletely checked, the bone fragments placed in apposition, the wound thoroughly douched with antiseptics, torn muscles and fascia sutured, the skin wound closed, and the arm carefully dressed and secured in wooden splints. This free opening and cleaning up of compound fractures is especially important when the forearm is involved, for in it non-union frequently occurs, owing to the interposition of muscle fragments or tendons between the ends of the bones. In the present case the arm was bound firmly to the side to insure perfect rest. After recovering from ether the young woman experienced little pain; the next morning her temperature was 99° F. It never rose higher, and we presumed fairly that the superficial wound had healed satisfactorily after six days. On removing the dressings we found our presumption to be justified. The skin wound was soundly healed ; there was no swelling or redness, and we were left to treat the case as a simple fracture. Another case was a much more difficult one, illustrating a point which I have made before. The man, a brakeman, was forty years old. Four months previously he had his left humerus broken by being crushed between two freight cars. The fracture was a compound one, but the external opening healed readily, and under a properly applied plaster-of-Paris dressing union of the bone was going on well, as we supposed. After a month, however, non-union was apparent, and after two months the condition had not improved. A careful investigation of the man's past history then revealed the fact that some five years before this he had a venereal sore, fohowed by an inguinal adenitis and a skin eruption, for which he submitted to about six months only of treatment. He was now put on mercurials and iodids for a presuma- ble syphiHs, with the result that after another month fair union was established, so that we find his left arm as sound as its fellow. That question of an old syphilitic infection is never to be lost sight of in these cases of delayed union. The other more frequent general diseases which may complicate recovery are tuberculosis, diabetes, malaria, and that indefinite thing which we call rheumatism. Our third case was a more serious affair than either of the two pre- ceding, but is interesting because it shows how bad may be the results which sometimes follow the careful conservative surgery even of to-day. The subject is a man of sixty who has all the appearance of having led a laborious life. He has an obvious arteriosclerosis, though a thorough examination of the chest and kidneys ehcits nothing abnormal. As old John Abernethy remarked on opening his surgical lectures a hundred years ago: " Now I say that local disease, injury, or irritation may affect the whole system; conversely, that disturbance of the whole system may affect any part." That ancient fact is the cmx on which this case turns. The man is a weaver. About six weeks before I saw him his left hand was caught in his machine and severely torn at the wrist. The 47 738 MINOR SURGERY — DISEASES OF STRUCTURE radius was fnicturcd, the ulna dislocated, the wrist-joint opened, the skin and other soft parts over the dorsum severely nian<;led, and he was brought to the Massachusetts Cieneral Hospital with the hand hang- ing- off, attached only by the skin and tendons of the front of the wrist. There again was the question of completing the amputation which the machine had begun, or of attempting to save the hand. I determined on the latter seemingly hopeless undertaking. After the usual carefid preparation, two loose fragments of the radius were removed, including the articulating surface, and the pro- truding end of the ulna was cut off, in order to convert the injury from a compound fracture and dislocation into a compound fracture which woidd be more likely to heal than would the contused and lacerated joint. As a result of this removal of the ends of the forearm bones, we produced a partial resection of the joint, which would mean for him at best a hand with considerable impairment of motion. Then the torn tendons were secured, trimmed up, and united, tape drainage was inserted, the skin wound sewn with silver wire, and the arm put up in the mill-board apparatus. The patient was put to bed and the limb slung in a hammock. The case went as badly as it could well have done. That night the patient's temperature was 100° F. and his pulse 100. The next morning the temperature and pulse were 101° and 90 respectively. The dressing was taken down, the skin stitches removed, and the wound cleaned up, but that night the temperature had reached 103° and the pulse 120. The next day, two days from the accident, the patient's condition was alarming. With temperature at 102° and pulse 112, he had every appearance of being thoroughly septic, as it is called. Evi- dently the wound was an active streptococcus factory, pouring pyo- genic organisms and their products into the general circulation. The patient's arm showed a striking picture — such a picture, fortunately, as we seldom see in these days. The wound was sloughy looking, and exuded a thin, sanious pus. The whole forearm and hand w^ere swollen, tense, red, and shiny. The skin of the back of the hand was blue and necrotic looking, and it was evident that we had to deal with the incep- tion of an acute gangrene. Not least significant was the patient's general appearance. He was hectic, anxious, and restless, with that almost indefinable septic look, with saffron skin and injected conjunctiva?, which experience teaches us to associate with these alarming cases. Of course, there was but one thing to do. The rotting arm w^as killing the man, and it must be taken off. I amputated it about 3 inches above the limits of the old wound, left the flaps wide open for the sake of more complete drainage, and had the satisfaction, the next day, to find him established on the road to convalescence. The further story is uneventful. One will scarcely find a case to illustrate better the extreme danger of some of these compound fractures, and the bearing which the patient's state of general health may have on the local lesion. Here the man's COMPOUND (open) fkactuues 739 premature old age, and the general impoverishment of his system, consequent upon an inefficient circulation, were the underlying and salient features. He could put up no fight against the ovei-whelming bacterial invasion, and so capitulated only in time to save his life." In a city the place to see compound fractures is at a general hospital. — you will rarely see these cases in private practice. Such injuries occur mostly among handicraftsmen, day laborers, and those persons engaged in extra-hazardous vocations, such as railway trainmen, line- men, roofers, firemen, and the like; and these men, when injured, are commonly taken at once to a hospital. So, too, with any person in any walk of life who may be injured in a street accident— he is im- mediately hurried to the hospital by the zealous bystanders or police. It is fortunate that this is so, for in a hospital is found the fullest equip- ment to meet these emergencies, and a competent surgeon is always on hand. The commonest and perhaps the most important of these com- pound fractures are mangled and lacerated hands. We see them daily. Let us study a man suffering from such an injury. I say that these accidents to the hand are most important because serious crippling or loss of the hand means a loss of livelihood to the victim, and to the surgeon each of these cases presents a fresh problem of great interest. Every half -inch of finger saved and every joint restored is of importance. Most of all the thumb, that distinctive mark of a higher evolution, is to be preserved if possible. The thumb without the fingers may still adorn a stump capable of grasping a tool and doing work, but a hand deprived of the thumb is a futile member. The present patient is a machinist, whose right hand was caught between cog-wheels. We take off the bloody wrappings and find all four fingers mangled, but the thumb uninjured. A flap of skin over the dorsum, with its pedicle toward the wrist, was torn up, disclosing the second and third metacarpal bones, which were fractured. The whole of the forefinger was mashed, the joints opened, and the distal phalanx wanting. There was no prospect of saving that forefinger, but the other fingers, though lacerated, might be saved. Such a hand means a study in reconstruction, and perhaps two hours of painstaking work at patching and mending. Ether and asepsis are our first steps; all bleeding is checked, every torn tendon is stitched and replaced, bits of destroyed tissue are trimmed away, hopelessly comminuted bone fragments are removed, each finger is treated as a separate problem and given its appropriate dressing, skin-flaps are dravm up to cover exposed stumps, and the forefinger is amputated at the middle of the first phalanx. When all this is accompHshed satisfactorily, the hand is spread out upon a well-padded splint, with dry gauzes about and between the fingers, and the limb to the elbow is put up in an abundant elastic-compression dressing. It is important, in such a case, as in the case of the man with a cut palm, that the muscles of the forearm and hand be immobilized absolutely. We must have no dragging on those freshly united tendons and delicate, new-forming tissues. 740 MINOR SURGERY — DISEASES OF STRUCTURE Then the arm is supported carefully in a sling or held high on the chest in a Velpeau bandage. If all goes well, the patient may expect the use of his hand by the end of two months, but we can give him no such positive assurance. Skin-flaps may lose their vitality; bones may suffer from osteomyelitis and become necrotic; tendons may slough; sinuses leading to deep-seated inflammations may persist for weeks, and many and various minor, secondary operations may be necessary before we are through with the case. But the great pre- liminary care is worth the patient's while and ours. ^^'ith such care we can promise him a useful hand ; without it he would have to expect a crippled, helpless claw. In connection with this subject of lacerated hands I must warn the reader that he will find the treatment of lacerated feet a still more difficult matter. It is not because there is anything peculiar in the structure of the feet, but because, owing to their dependent position, their circulation is not so good as is that of the hands, except in the case of the young and vigorous. Take two similar cases — a man with a jammed thumb and a man with a jammed toe. One may dress up the former and send him home, to find, in the course of a couple of weeks, that he is quite well. One may dress the man with the jammed toe and send him off about his business, and what does one find? By the end of two weeks, in sj^ite of careful oversight, the toe is far from healed: it is red, tender, and slightly septic; the whole foot is swollen and tender, and very hkely there is a bit of necrotic phalanx to be felt. This untoward result is due to no lack of aseptic precautions, but to the fact that we have failed to observe our second cardinal principle — support. One cannot safely send these patients out to knock about the streets. Either they must be put to bed with the leg elevated — the best thing by far — or the}' must be instructed to bear no weight on the foot and to keep it up on a chair or sofa except when necessarily in use. The point sounds like a small one, but it is salient. So much for compound fractures — perhaps the most important division of traumatic surgery. We have but skirted the border of a great subject, but sufficiently near, I tnist, to show that here, as in the lesser lesions considered, the same broad, inevitable principles constantly must be applied. GRANULATING WOUNDS AND VARICOSE ULCERS There exists in the minds of students, and often of practitioners as well, a confusion regarding ulcei's and granulating woimds. It is a natural' confusion, for the two conditions overlap and run into each other. An ulcer may be described as a superficial solution in con- tinuity, which shows no tendency to heal; a granulating wound, as a solution in continuity, which shows a tendency to heal. Of course, such a definition is a general one, but it will answer our present purposes. Ordinarily, there is no question when we are dealing with a granu- GRANULATING WOUNDS AND VARICOSE ULCERS 741 luting wound. We see the red, velvety granulations shrinking in area steadily, with little projections of new skin shooting in, and the process of repair so constant and inevitable that one may appreciate the changes from day to day. In regard to such a healthy granulating wound there are two ques- tions which the student is always asking, and about which he seems to feel that he gets very httle light. With what applications shall it be treated, and how often shall the dressing be changed? Ordinarily, the answer to that first question is a very simple one when the wound is in a healthy individual. I have shown, for instance, a woman, whose breast was removed for sarcoma some three weeks before. The skin-flaps were not drawn tightly together at one point, with the result that she had on the front of the chest a superficial open wound about the size of a silver dollar. It was clean, flat, bright crimson, and did not bleed easily. It will heal over in a few days, no matter how treated, provided only and this is important — provided it be kept clean. One can wash it with corrosive alcohol or creolin, put on a gauze cocoon, and leave it for three or four days. The raw area shrinks from day to day. Such wounds as this require no special care. On the other hand, take the case of a granulating wound on the back of the neck in a patient fifty years old who has 2 per cent, of sugar in his urine, for which he is under treatment. Two weeks previously he showed on the back of his neck a carbuncle the size of an English walnut. We excised cleanly the carbuncle, and so stopped the process. There was no return of the active local infection, but the wound did not heal. The raw surface, as large as the top of an egg-cup, remained without healing, the granulations dark purple, soft, spongy, bleeding easily when handled, and overlapping in fringes about the edges. That overlapping we caU exuberant granulations; it is a perfectly harmless condition, and is easily remedied. It is the condition known to the laity as "proud flesh," and is always referred to with horror by them — just why is not clear. There are various methods of treating such granulations, but all methods come down to this, that the granulations must be trimmed down and the wound stimulated into proper activity, so that it shall have the vigorous healthy appearance which we saw in the case of the woman. With the scissors cut off these redundancies, — they are abso- lutely insensitive, — and after checking the oozing by sponge pressure, wipe over the whole wound with the stick of silver nitrate. Then apply a dry gauze dressing. Every other day the man returns, and we soon see the wound closing in. Another excellent method of treat- ing such a wound, after trimming the granulations, is to dust it thickly with some simple drying powder, such as dermatol or aristol. But after all, what one must bear in mind is that the wound is to be kept clean and the granulations frequently trimmed down. Our familiar support- ing bandage must never be omitted, for the pressure it exercises helps the circulation in the parts. 742 MINOR SURGEUY — DISEASES OF STRICTURE A third type of firanuluting avouiuI is seen in a boy who received a severe kick on the shin about a month before I showed him to my chiss. The periosteum and bone were not injured, but he slunved a superficial wound, long and narrow, as though one had torn up the skin for a distance of 5 inches with the finger-nail. One week later this long, narrow wound, in the apparently healthy lad, began to be lined with small, fiat, dull, red granulations, and thus it had remained. It refused to heal. It had been scarified,' cureted, and wiped frequently with the caustic, but without avail. We had the lad get out into the country to see what out-of-doors life would do for him. Meantime I dressed the wound daily with a stimulating lotion on gauze and bandaged the leg from toes to mid-thigh. In such cases we find diluted tincture of myrrh, 1 part in 20 of water, or pure balsam of copaiba, to be excellent. I have always been pleased, r- '■'^;»i-'*^: Fig. 460. — Incircling ulcer of the leg (Massachusetts General Hospital). too, with the action of Gamgee's favorite application: Borax, 1 part; compoimd tincture of lavendar, 8 parts; glycerin, 4 parts; water, 24 parts. Such, briefly, are some of the methods of treating these open wounds. We find in the t)ooks and are told by physicians of innumerable other lotions, ointments, and applications. Many of them doubtless are useful — certainly most of them are harmless; but, after all, what we must remember is to keep the wound clean and to give nature a chance. Now let us regard another class of cases — varicose ulcers, allied to granulating wounds, cases which are a weariness often to students and dressers, for long-standing ulcers become an opprolirium to the clinic. Yet they should not be so. These ulcers are grievous afflictions to their victims; they belong to an interesting class of pathologic processes, and they heal under proper treatment. For hundreds of years surgeons have talked and written about GRANULATING WOUNDS AND VARICOSE ULCERS 743. varicose ulcers, and the opinions of the best surgeons regarding their nature and treatment have always been correct, yet even to-day one sometimes sees the cases drag on an interminable course, submitted to a treatment which is amazing and discouraging. One may usually tell a varicose ulcer at a glance. It is on the shm, below the middle of the leg; above and about it are enlarged superficial veins, and commonly the leg is swollen more or less. In few lesions is the cause of the trouble as obvious as in the case of these ulcers. Ivnow- ing the cause, one must remedy that, and in so doing attack the disease at^its source. These ulcers are due to varicose veins, so we must cure the varicose veins, or at least we must support and relieve them. This is such a transparent truism that it seems as though it should be apparent to the meanest intellect, yet wise men are seen to pass it by. Think for a moment of what the complex process is. First, there arises the dilatation of the veins, a condition lasting perhaps for years; gradually, as the walls of the veins become thinned and inelastic and their valves incompetent, a condition of venous stasis results. A thm serum oozes out into the surrounding tissues and causes the edematous swelling. At the same time there is an exudation of red blood-corpus- cles, which produce an extensive pigmentation of the skin, associated not infrequently with an eczema. As a result of all this the nutrition of the leg is greatly impaired, and the ideal conditions favoring an infection with destruction of tissue are present. Sometimes, as a result of thrombosis of the veins and malnutrition of the surrounding parts, a phlebitis or a periphlebitis is seen; there may be mpture of a vein even with serious hemorrhage; but more commonly, as a result of some sHght blow, or even scratch, a superficial skin lesion is caused. This refuses to heal in the sodden tissues,' bacteria rush m, and a de- structive ulcer is formed. ■ It is for this ulcer that the victim seeks advice at last. He seeks advice and I regret to say he sometimes is given plasters and washes, —ostensibly for the eczema, I suppose. With our knowledge of the cause of his trouble we say that such treatment is preposterous. _ Now let us consider one of these unfortunate patients. He is a man of forty-five; a day laborer; a man who stands constantly on his legs The pain of his disease has disabled him utterly. One observes, in the first place, the great size of his calves and feet. He is not a large man; he weighs perhaps 165 pounds, but his right leg. which is the seat of the ulcer, measures 20 inches. The whole leg below the knee is of a dark, reddish-browTi color, mottled and shmy. There the veins are disguised, but behind the knee, in the popliteal space, and along the course of the internal saphenous you see the veins standing out in great bunches. Over the front of the shin, and spreading back into the calf, is an irregular ugly ulcer, as large as one's outspread hand 1*^ edges are indurated and elevated, and it is lined with sloughy, dull red, tiabby granulations. As the man says truly, it is a very sore leg. The patient has been lying on the examining table for half an hour, with his leg supported at an angle of 45 degrees. That has demonstrated 744 MINOR SURGEKY — DISEASES OF STRUCTURE two things: It has given us an idea of the extent of the sweUing, for now we find the calf to measure but 16A inches in circumference, — a shrinkage of 'Sh inches, — and it has given us an important clue as to treatment. Indeed, it has brought us back to our first principles, and shown us the importance of elevation and support. For let me assert that the method ])y which most cjuickly we should secure a healing would be to put the man to bed, to bandage properly the leg and swing it in a hammock. Thus the veins would be kept constantly emptied by the action of gravity; the circulation would be quickened and the nutrition reestal)lished ; the exudate would be absorbed in a few days, and the ulcer would be converted into a granulating wound. For various reasons such an admirable method of treatment may not be instituted in the case we are considering, so we must adopt the next best method, and, on the whole, it is the one most practicable in such cases. In the first place, when there is any considerable edema present, always order the half-hour of elevation. At the end of that time we find that we have to deal with a leg of a more nearly normal size, with edema diminished, and veins emptied of their accumulations. Next, to clean up the sloughy ulcer with its indurated border, let us apply a gauze pad wmng out of pure glycerin, overlapping the edges. The glycerin acts to draw out the serum from the tissues and rapidly softens the indurations. If we choose, we may etherize the patient and curet the ulcer and its edges, but this rarely is necessary. Then from toes to mid-thigh apply firmly, snugly, and with uniform elastic compres- sion our wadding rollers of many thicknesses and a cotton bandage. Now, whatever position the patient assumes, the veins cannot again become distended, the leg cannot swell, and the nutrition of the parts cannot seriously be disturbed. The patient is directed to keep as quiet as possible for three or four days and to have his leg up on a chair most of the time, but within the week he will go back to work in some degree of comfort. After the first day he will return to have the glycerin pad removed and the bandages reapplied. Consider next a second man, who is suffering from a similar ulcer and has been under treatment for three days. He was dressed with our glycerin pad and supporting bandage, which has been once renewed. We find now a condition very different from that of our control patient. The leg is still swollen and edematous, but not markedly so. The veins are inconspicuous, and the ulcer itself, instead of being indolent and sloughy looking, is lined with red and fairly healthy granulations; in other words, it is taking on the characteristics of a granulating wound. As for further treatment, the important thing is to continue our support, without which the lesion would quickly relapse into an ugly ulcer. To the granulations apply sterilized al)sorb- ent gauze. Nothing else is needed, and by continuing in this course for three weeks, we should find the wound nearly healed and the man going about in normal, comfortable fashion. fklon; whitlow; i-akonychia; palmar abscess 745 FELON; WHITLOW; PARONYCHIA; PALMAR ABSCESS We tfluiU iiiul it luuxl to define the first three wurds, which give a title to this piiragrapli. Felon and whitlow have no proper etymologic reason for existence; paronijckia is derived obviously from Uapd, around, and ovo^, nail; palmar abscess is self-evident. I make this seemingly needless discourse about definitions because no two surgeons will be found to agree about the meaning of those first three words, and the medical dictionaries even are at loggerheads. Felon means one guilty of felony, a uickecl cruel person, hence the word has been applied to a cruel infection. Whitlow means literally a white flame; "a painful inflammation tending to suppurate, in the fingers or toes." ^ That seems a fairly good definition. Many surgeons regiird whitlow as identical with, felon; I do so myself, and as I find no great authority or even well-established custom to oppose me, I shall continue to do so. For us whitlow and felon are interchangeable terms. But paronychia— there is our rock of offense, for fully half the authorities make it identical with whitlow and felon.- So we are left to follow our own fancies, and I have taken the liberty of following mine so far as to contrive two definitions which I beHeve to be descrip- tive, convenient, and fairly accurate: As whitlow is felon, and the latter word is in more common use, I shall drop the term "whitlow." A felon is an acute infection of the finger (or toe), progressive, with a tendency to involve the bone. A paronychia is an acute infection of the finger (or toe), progressive, situated near the nail, which it tends to involve. Bear in mind that paronychia may spread further and involve the whole finger— in which case it should more properly be caUed a felon. And bear in mind also that the great majority of felons are situated over the terminal phalanx. This is a beginning only of the controversy. We could go on tor an hour juggling terms and disputing as to w^hat does or what does not constitute felon. . . . ■ Felon.— Conceive, then, of felon as an acute, progressive infection, situated anywhere on the finger. It may be superficial, it may be deep, it may be both superficial and deep. Take that last conception as an example of a common form of felon and examine a special case. One week ago a patient pricked her finger with a carpet-tack. The little wound healed apparently, but after three days the end of the finger became red, and the skin over the pulp become elevated somewhat in the form of an ordinary blister. But there was pam, and 1 Chambers' Etymofogical Dictionary. , 2 Foster, Dunglison, Keating, Gould, and Duane group felon, whtlo^\, and paronychia under one head, and caU the hybrid affection ' 'penplif^ngeal abscess The Century Dictionary: " Felon, an acute and painful inflammation of ttie deeper tissues of the finger and toe, especiaUy of the distal phalanx; generally seated near the nail." 746 MINUR SURGERY — DISEASES OF STRUCTURE there is pain now — throbbing, wearing pain. We tie a rul)ber tourni- quet about the base of the finger and inject a few (hxjps of 2 per cent, cocain along the course of each lateral nerve. Then, with the scissors, we trim off the blister. That leaves a sore with a red, mottled surface about the size of a silver dime. It looks like a granulating area. All the seropus contained in the blister has been evacuated, and one would suppose that here was an end of the affair. If now I take the finger in my hand and gently squeeze it, you see a minute drop of pus exude slowly from a point in the granulations. That means that there is a little track connecting the superficial cavity we have opened with a deeper cavity. This felon is a compound affair, with two pus chambers in tiers, one above the other. They are connected by the minute channel which was perhaps the original track of the carpet- tack, or perhaps was caused by the inflammatory action itself. Treatment. — This form of felon with its two chambers has been felicitously termed a "shirt-stud abscess." There may be two or more connecting channels, but the name is just as good. So, when we open a superficial felon, let us remember that a felon is progressive, and search for that second chamber. Now we open the deeper pocket, and find ourselves on the periosteum. We clean out the little cavity; wipe it thoroughly with dioxid of hydrogen, lay in it gently a bit of absorbent tape, wrap the finger in a hot creolin poultice, bandage the hand and forearm with elastic compression, and suspend them in a sling. Let me say one word about poultices} They have been used from time immemorial for the comfort they bring to the affected part. Their action is to stimulate the superficial circulation, and thus, by relieving congestion, to check inflammatory action and allay pain. Such a use of poultices is as comforting to-day as ever it was. A poultice must supply heat and moisture; deprived of either, it is no longer a poultice. The materials of which poultices have been made are many, but mostly surgeons try to employ some vehicle which shall retain heat. Such vehicles are found in Indian meal, flaxseed, and the various cereals. They remain moist and warm for a long time, but they are beautiful culture-media. For a vigorous infection-spread- ing agent, recommend me to the old-fashioned bread-and-milk poultice. With Listerism there came in the so-called antiseptic poultice. As commonly used it is not antiseptic. The best that can be said of it in that regard is that it is often aseptic. When properly prepared, it is a useful dressing, because it is sterile and because, by supplying heat and moisture, it stimulates the reparative processes. Then, too, it is easily applied. So one sees that in the use of the properly constructed and applied poultice w^e return again to our fiist principles — we support the part and we stimulate and equalize the circulation. That form of antiseptic poultice which I prefer is made of sheet- wadding pads wa-apped in absorbent gauze and covered with some waterproof material, like oiled-silk or parchment paper. The pads * Compare the action of poultices with the Bier treatment. felon; whitlow; paronychlv; palmar abscess 747 are wrung out of a hot creolin solution, 1 : 200. One may use bichlorid or boric acid, but carbolic acid never. The poultices should do much more than cover the affected region only. If the whole finger is in- volved, wrap the hand; if the hand is involved, include the forearm in the poultice. Thus we shall quiet the adjacent muscles and protect the efferent lymphatics. It is well also to put on a light splint outside of the poultice for more perfect immobilization of the parts. Then as to the drainage of these abscesses — gauze wicking is usually sufficient. Do not jpack the cut with gauze. That will cork up the r: ' J. • ^ Fig. 461. — Examining infected axilla. pus. Gauze 'packing is never used except to check hemorrhage. To drain, lay gently into the cut one or two wicks or tapes. These will carry off by capillarity the secretions, and, being interposed between the cut edges, will prevent a superficial gluing together of the skin wound and a consequent pocketing and burrowing of pus in the deeper parts. To demonstrate further the treatment of felons let us consider a second case. The patient has been aware of a throbbing pain, in- creasing in severity, for four days, over the middle phalanx of his ring-finger. The primaiy cause of the trouble is unknoTVTi to him. We observe that the whole finger is hot and swollen, and on compressing 748 MIXOR SURGERY — DISEASES OF STRUCTURE between one's thumb and fin^or the lateral vessels on either side of his finger one plainly fools thoni throbbing. That is a distinctive and interesting point in the tliagnosis of localized inflammations of this type. You will not discover that pulse in cases of sprains or rheu- matoid affections. The man's finger is not only swollen throughout, but its palmar skin is reddened, elevated, and excessively tender. In feeling carefully in his axilla, one detects an enlarged and painful node. His body temperature is not elevated, his pulse is not rapid, nor is there a noteworthy leukocytosis — the white count being 9000; but he is tired from loss of sleep and weary with the constant pain. On carrying the knife deeply down through the skin and laying bare the tendon-sheath, we give vent at first to an abundant bloody oozing, which is good. Then there follow half a dozen drops of pus, in which one will probably find streptococci in pure culture. If, now, content with this cut, we apply the dressing, to-morrow may show us the super- ficial parts mostly glued together. That is a condition we do not want, for the wound must be made to heal by granulation from the bottom. To favor such healing, trim off the skin-edges so that they cannot readily be brought together — a simple and veiy useful maneuver. Now we apply the poultice, light splint, bandage, and sling. Properly the poultice should be changed twice a day at least, and by the fourth day we should begin to see a clean, granulating wound. The man may have pain, and may need a small dose of morphin. A certain amount of pain nearly always follows a cocain operation on a felon, but by the next day the patient should be in comfort. These two cases have been simple ones, but all felons are by no means so easy of treatment. The pus burrows; tendons, bones, and joints are involved; slashing incisions and amputations may be neces- sary, and at the best some impairment of function is apt to ensue. Such results you shall see daily in my clinic. The therapeutic measures to be applied differ in degree only from those you have seen. Pus is to be sought out, drainage is to be maintained, asepsis and sup- port are vigorously to be enforced, pain is to be relieved, and, always, the general condition of the patient is to be considered and strengthened so far as well may be.^ Let us study a third patient, who presents us with an example of paronychia. In the limited sense in which w^e use the term, "parony- chia'' is the common nursery "run-round." This child pulled a hang- nail a few days ago until she drew blood, and so infection entered in. Two days before she came to us the skin about the base of her nail was reddened and painful, forming a crescentic swelling. On our first inspection there is pus obviously present, for it shows creamy through the thin pellicle. There is a common way — a common but wrong way — of opening these little abscesses. That wrong way is to cocainize the finger and draw the knife in a semicircle through the skin about the base of the nail. ^ The opsonins and Bier's treatment are giving us constantly better results in the treatment of these serious infections. felon; whitlow; paronychia; palmar abscess 749 So one will evacuate the pus, but will have left an ugly sore to granulate slowly up with the underlying nail at its bottom. Here is a better way. Lay a narrow-bladcd knife flat upon the nail with the knifc-ixMiit against the inflamed skin, and by a little gentle prying, which should be painless, insert it along the skin-edge and the base of the abscess. Withdraw the point, when we see it followed by a jet of pus. By a little manipulation the cavity is now evacuated; a poultice is then applied. Unless the nail and matrix have become in- volved in the infection, sound healing should now be a matter of two or three days only. As in the discussion of felons, so here, we have scarcely more than touched upon a broad subject. This infection may rapidly invade the finger. It may attack and destroy nail and matrix, and involve peri- osteum, bone, joint, and tendon. There is no limit to its possible tij£i^ Fig. 462. — Opening paronychia along nail. ravages, but for the avoidance of confusion, when the infection has passed beyond the region of the nail, we speak of it as felon and not as paronychia. Palmar abscess is a further development of these hand infections. To it felon and paronychia naturally and inevitably lead. It is a lesion of great interest — in its pathology, its treatment, and its capacity for far-reaching damage. In it the infection usually starts in the palm, but it may begin in one of the fingers and spread to the palm. The methods of infection are therefore various, but perhaps the commonest method is that seen in the hand of the laboring man. Take the case of a gardener, for example. His hand bears heavy cal- losities, which have become so hard as to press upon and irritate the underlying soft structures. This bruising has caused a considerable blister, which has become infected from the overlying skin, and in turn has passed on its irritating properties to the deeper parts. 750 MINOR SURGERY — DISEASES OF STRUCTURE As one looks at the huiul, it appears everywhere swollen — back as well as front. That puffy, reddened dorsum is swollen from edema. If one were to cut into it, one would draw serum and blood only. But the palm shows a condition quite different. It is not so greatly distended in appearance as is the tlorsum, for its deep structures, bound down by the dense palmar fascia, cannot greatly swell. The pain is there, how- ever; and it is all the more severe because the fascia does so limit the swelling. In order to escape without our aid the pus must burrow up under the annular ligament, into the forearm, and that is what we fear. So you see the palm of the hand to be tense and brawny, but not greatly swollen. It is exquisitely sensitive to pressure. The pus must be let out quickly, and here again we are presented with a problem which is rendered interesting by reason of anatomic complications. Few other regions of the body contain so many and such diverse structures compressed into so small an area. There is here a labyrinth of tendons, nerves, vessels, and fascise — to say nothing of tendon-sheaths, small muscles, and bones. All these structures are essential to the proper use of the hand — that wonderful piece of mechanism. We cannot go roughly slashing into it without crippling it, yet to get out the pus we must in a fashion slash. It used to be taught as a safe rule, and those who so taught were in the main correct, that when cutting into the palm one should make incisions short, multiple, and parallel to the bones, thus avoiding, so far as possible, the delicate structures of the hand. That plan is not a bacl plan — indeed, it is the one commonly followed still, but it has this disadvantage, that through these straight incisions the pus is sought somewhat blindly and with difficulty, while the incisions tend to early closure, thus damming in the discharges and necessitating a second operation often. Moreover, such wounds heal with disabling scars, which are bound closely to the underlying parts and seriously limit motion. My colleague, W. A. Brooks, Jr., has devised an incision which I prefer. The patient is etherized. While his hand is held firmly out- spread, we outline a semicircular flap which includes the whole of the palm practically. Enter the knife over the second metacarpophalan- geal joint, and after sweeping it round the palm, bring it out at the base of the thenar eminence; in other words, the flap is to be turned back on the thumb as a pivot. Rapidly dissecting away the skin, we now expose completely the palmar fascia. A little pus oozes through it at various openings. Enlarge the openings with a blunt scissors and rapidly, without damage to structure, follow up and clean out all the cavities. Thus we have dealt with a really beautiful and well-exposed dissection of the palm, and have avoided easily the important arteries, nerves, and tendons, for we have seen them, and we have searched out the burrowing pus far more thoroughly than was possible by the old blind method. Now disinfect carefully the whole hand. As for drainage and the after-treatment : Wicks are led out from all the pockets; a thin layer of gauze is felon; whitlow; paronychia; palmar abscess 751 spread over the whole exposed surface, and the skin-flap is laid back over the gauze. In the subsequent dressings, when necessary, the skin-flap maj^ again be turned aside and the depths of the wound may again easily be explored. Judging by experience, we should find the inflammation subsiding in a day or two, when the wicks gradually will be removed. By the end of a week the palm and the under surface of the flap will be covered with granulations. Then, if all looks clean and sound, we stitch the skin back into place and look for a rapid healing by a delayed first intention. To facilitate the sewing back of the flap we usually pass so-called provisional stitches at the time of the original operation. When the time comes, they will be tied. Fig. 463. — Brooks' incision for palmar abscess. For the first four or five days it is well to dress the hand and fore- arm in a large creolin poultice with a splint, but this may be abandoned soon for the gauze dressing with elastic compression and elevation. One is surprised to see how useful and comely a hand will result from all this. The scar will be there, of course, but it will not be especi- ally troublesome, and the function of the hand will generally be much better than was the case when multiple Hnear incisions were used._ Again, let me warn the reader, that in spite of what I have said of a flap at the thenar eminence one must never operate by rule of thumb. Broadly, this operation is a good operation, but diverse conditions will present themselves. No two cases are alike, and while one must strive always to observe general principles, he must apply also a broader common sense. 752 MINOR SURGEUY — DISEASES OF STKLCTUHE BOILS; CARBUNCLES Boils. — The treatment of boils ma}- seem to be a very minor part of minor surgery, yet there are few curable conditions more trouble- some than furunculosis. Some months ago there came to see me a man who is the chief of police in a town near Boston. He had upon the back of his neck two boils and the scars of half a dozen others. For four months he had boon suffering from these pests — in constant discomfort, with a sore and painful neck; his sleep broken, his appetite impaired, and his health ])ccoming undermined. On inquiry I learned that he had gone ten }-ears without a day's vacation, and that for six months l)efore the appearance of his boils he had been feeling nin-down and debilitated from that condition of faulty metabolism w^hich we call muscular rheumatism. I gave him a simple cleansing wash for the neck and a course of aperient waters. I enjoined a two weeks' vacation, and the following tonic : sulphate of iron, 2 drams ; sulphate of magnesia, 6 drams ; dilute sulphuric acid, 6 drams; syrup of ginger, 4 drams; water, 9 drams. The dose is one teaspoonful in water after meals. To the boils I applied a soft protective cotton dressing merely. Ten days later the man wrote to me that his boils had disappeared and that he was feeling well. That case illustrates one of the most important points one must make in this connection. It is the point I have so often made before. We must regard the patient's general condition. And boils are usually a manifestation of a general condition. They indicate some form of malnutrition, and must be treated on that basis. Billings' Dictionary defines a boil as "& painful conic or rounded swelling of the skin, due to inflammation about a hair-follicle, a Mei- bomian gland, or a sweat-gland." That is a fair enough definition, and if we turn to page 172 of Warren's Surgical Pathology we shall find the nature of the process exhaustively described. The point of it all, so far as the clinician is concerned, is that the organisms normally present in the skin gain lodgment in some of the glands or ducts and then multiply. The active development of these colonies of bacteria produces small areas of connective-tissue necrosis. This necrotic por- tion acts as a foreign body, and nature proceeds to throw it off as a "core." The process of throwing it off gives rise to further inflamma- tion, with the resulting pus-formation and swelling. After the core is thro'\\"noff, there remains a little pit, which must heal by granulation. So, we see, there are three stages in the life history of a boil, and each stage demands its appropriate treatment. There is the first stage, when we see a small superficial pustule only; the second stage, when we see a much larger mass — elevated, indurated, and ])ainful, containing its core; and the third stage of a crater-like but subsiding swelling. Commonly, a patient comes to the surgeon with a well-developed boil in the second stage, and, in its neighborhood, two or three incipient boils or pustules. If the case is a chronic one, make up your mind boils; carbuncles 753 about the patient's general condition, especially as regards diabetes and rheumatism. Take another patient as a good example of what we are describing. He is a night watchman whose daytime sleep is disturbed. He is given to rather excessive whisky drinking, and is feeling pretty well " done up." He has a poor appetite, constipation, a furred tongue, and is a striking type of the tired man who is burning the candle at both ends. I need not trouble you with details of general treatment in his case except to say that we should stop his liquor, and give him a course of Carlsbad salts, with 5 grains of Blaud's pill before his meals. Look- ing now at the back of his neck, we see on the right side a conic sweUing the size of a silver ''quarter." It is reddened at the center, where it is beginning to break down and soften, but everpvhere else it is indur- ated. It is very tender to the touch, painful on pressure, and the man says it ''feels sore all round." To the left of it are three little pustules, with reddened areolae, each about half the size of one's little finger-nail. In the first place, as regards these incipient boils, let me assert with much assurance that they may be aborted. The old- fashioned method was to poultice the back of the neck and bring the whole crop "to a head." Do not do it. There are scoffers who will say that boils cannot be aborted. I doubt if they have tried faithfully any method. Here are two methods. One may prick the little pustule and wipe out the minute cavity with a probe dipped in pure carbohc acid. That often will suffice, but I have not found it so successful as the hypodermic injection of very small quantities of some strong anti- septic. In the first place, we cleanse the neck with soap and water and alcohol. Then inject 5 or 6 minims of cocain, in 4 per cent, solution, under the infected areas. Now into this anesthetized zone, along the cocain track, inject under each pustule 2 minims of pure styron— an ancient but efficient balsamic antiseptic. I prefer it to carboHc acid, because more thoroughly it permeates the affected tissues. The result of this injection is to destroy the active bacteria and to convert the infected area into an aseptic eschar. The immediate outcome, so far as the patient is concerned, is that the sense of burning and discomfort disappears in a few minutes; without further sensation, the eschar is thrown off and the Httle wound heals up. Remember to use cocain before these injections of styron, for the styron used without such pre- liminary treatment causes a few moments of severe pain. I am satisfied, from a fairly wide experience with this method of aborting boils, that it will usually be found successful. A young man consulted me recently who had pustule after pustule appear on his neck for a period of several weeks. One of them ran a severe course and had to be opened and cureted twice. Into the other incipient furuncles— perhaps a dozen or more, as they appeared from week to week— I injected styron and checked them at once. Finally, with tonics and general treatment, the malady subsided.^ 1 In these cases I think highly of opsonic vaccines (Staphylococcus aureus). 48 754 MINOR SURGERY — DISEASES OF STRUCTURE There is another method of treatment which another patient, a medical student, illustrates. He luul a slightly septic finger, which healed without trouble, but he became " run down " and developed a crop of boils on his left arm. They were treated by his friends and the surgeons in various dispensaries, where he kept at his work. They were opened, injected, poulticed, time after time, but continually re- curred until he became discouraged and his life became a burden. I had seen him several times, but was unable to check the process, and there seemed to be nothing for it but to send him away on a long vacation. Finally, when he came here I determined to take a leaf from the book of my friend, H. L. Burrell, and try the effect of a carefull}^ applied Gamgee dressing. At that time the forearm had on it three incipient boils and the healing scars of a half-dozen others. The arm was care- fully disinfected, wrapped in absorbent gauze, and put up, from fingers to shoulder, in our wadding and mill-board apparatus, with firm com- pression. A sling, of course, completed the equipment. That dressing was put on one Friday and remained undisturbed until the following Tuesday. I then removed it, to find the arm clean and shrunken, the little red boils shriveled, and the old scars practically sound. That was an interesting experiment, and certainly it shows in a most striking manner the ever-present value of our familiar first principles — support, immobilization, elevation. When a boil has developed fully, or " come to a head, " as the saying is, the treatment is simple and obvious. There is then no special in- terest in it. We must open it and clean it out. Cocainize it first, of course, by one or two deep injections along its borders. Make a crucial incision or, what is better, excise a little cone at its apex, about half as large as a silver dime. This excision will usually bring with it the core. Then scrape the cavity clean and drain it with a bit of gauze. For a day or two a creolin poultice will be a great comfort to the patient; after that, until the wound is healed, a cotton dressing is convenient and comfortable. One little note : never plaster a cotton dressing down with adhesive strapping. It is dirty and inefTective compared with collodion, and the taking-off process is painful. The collodion dressing may always easily be soaked off with alcohol. Carbuncle. — When we come to deal with carbuncles, we have a quite different problem — different in the extent and gravity of the process, but not so different in its causation and development. Observe two patients. The first, a woman, has below the occipital protuberance, and above the line of her hair, a conic swelling about the size of a silver dollar. Part the hair and expose the swelling, when we note that its apex has an excoriated look, and that there are three little craters from which a drop or two of pus may be squeezed. The little mass is brawny to feel and is quite deeply seated. Take it as a whole, however, it resembles closely a boil, and one might readily mis- take it for a boil. It is a carbuncle in its early stages. In comparison, the process in the second patient, a man, is much further advanced. It is in the common location on the back of the boils; carbuncles 755 neck, on the left side, below the line of the hair, and to look at appears to be as large as the top of a small tea-cup; when we handle it, how- ever, it is found to be deeply seated, with a widely indurated base, nearly as large as one's palm, about it. It is flattened at its top and has a half-dozen little craters from which pus oozes and bits of white sloughs protrude. That is a large carbuncle. Both patients are de- Fig. 464. — Excision of carbuncle. bilitated — the woman from a week's pain and discomfort, the man from nearly three weeks of a similar experience. Both cases are uncompli- cated. The urines are free from sugar; both patients are in their prime and of previous good health. ^Tiat is a carbuncle and wherein does it differ from a boil? Billings' Dictionary defines carbuncle as "A circumscribed inflam- mation of skin and subcutaneous connective tissue, terminating in a slough." More than that, it is usually a gangrenous inflammation. It ■756 MINOR SURGERY — DISEASES OY STRUCTURE begins on the skin, us does a boil, but it spreads much deeper and, as one would expect, it is produced by the Staphylococcus pyo-ing results, for the secretions are thereby increased, the circula- tion improved, the appetite, sleep, and mental state stimulated, and the convalescence, after the patient's getting- out of bed, materially and happily abridged. 1 Mechanical massage (Zander treatment) and hydrotherapy are valuable sub- stitutes for manual massage. CHAPTER XXVII SHOCK; BLOOD-VESSELS; LYMPHATICS; MUSCLES; TEN- DONS; BURSAE; SKIN Shock and Collapse Shock and collapse are two ancient terms used by surgeons to indicate an extreme bodily depression; and a distinction between the two conditions has been asserted from old time. In truth, one cannot but feel that such a distinction is artificial, and that, as the words are commonly employed, shock is a state of extreme collapse, or vice versa, if you please. Nevertheless, Crile differentiates the two in a recent writing, regarding shock as an exhaustion of the vasomotor center, and collapse as an inhibition of the vasomotor center. Nearly thirty years ago William S. Savory, pubhshing in Holmes's System of Surgery: wrote: ''Life may be destroyed by certain agents which leave no visible traces of their operation in any part of the body. Some forms of injury, as, for instance, a blow on the epigastrium, may produce sudden death, and yet the most searching scrutiny shall fail to detect the slightest physical or chemical change in any organ or structure. Nay, further: life may be abruptly terminated by causes yet more subtle, such as sudden and powerful emotions of the mind. This kind of death is very expressively termed death from shock." In recent years, thanks to the inquiries of Crile, Howell, Porter, and other physiologists, we have learned to estimate more nearly the causes of shock— through investigation upon living animals, though physiologists are not yet in accord. To quote from Bloodgood: "For practical purposes shock shall be considered a condition of general depression produced by various causes. These factors act through the medium of afferent nerves upon various centers in the spinal cord and brain, especially the vasomotor centers. Howell, from his physiologic ex- periments, recognizes a cardiac shock as well as a vasomotor shock. It is a question whether the sympathetic ganglia are also deleteriously influenced by the various factors which may produce shock.'' These quotations will show the reader that the situation is not yet clear, though it is becoming increasingly evident that exhaustion and paralysis of the vasomotor center are important elements in shock, while at the same time there is excellent reason to suppose that the heart's action may fail through causes not connected with the vaso- motor center; for example, through irritation or damage to the im- portant cervical sympathetic gangha. In this brief writing one is not permitted to discuss at length the interesting and important physiologic 767 768 MINOR SURGERY — DISEASES OF STRUCTURE experiments bearing upon the subject of shock, but I refer the reader to the admirable publications of Crile, Howell, Boise, Porter, Blood- good, Mummery, and Sheen. ^ The most notable physiologic phenomenon in the condition of shock is the abnormally low blood-pressure, though low blood-pressure may be found associated with conditions other than shock. In shock there are further changes also — an alteration in respiration and the heart's action, a modified or depressed mental state, loss of power in both forms of muscles, a diminution in the glandular secretions, a lowering of the body's temperature. The condition of the circulation is extremely interesting, and we seem justified in concluding that a great part of the body's blood does not circulate freely through the arteries, but accumulates in the venous trunks, especially in the abdom- inal veins, so that the condition is equivalent to an internal or intra- venous hemorrhage. The condition of shock, therefore, simulates closely the condition seen in cases of hemorrhage, and we know that hemor- rhage is one of the important factors in the production of shock. The leading symptoms of shock are those of an acute anemia. The blood-pressure is low, often below 50 mm. of mercury, and the pulse is usually rapid and soft, though it may rarely become slowed. The output of the heart constantly diminishes as the shock deepens; the face becomes blanched; the breathing becomes rapid, sighing, irregular, and of the Chej^ne-Stokes variety; the muscular systems are relaxed; the reflexes are diminished; the sphincters are relaxed, and voluntary muscular action is abolished. The functions of diges- tion and of renal secretion fail also, while the skin becomes moist and cold. The patient usually is apathetic, though he may be talkative and excitable rarely. The blanched face appears shi-unken, pinched, and elongated, while the chin droops and languor marks the expression. The eyes grow dim and turn upward beneath the half-closed lids, but the pupils react markedly to light. Should the patient die, the symp- toms persist, becoming constantly more marked until the end. In case of recovery, however, one notes first a slight improvement in the rate and volume of the pulse, after which the color returns gradually and the patient begins to rouse himself and take notice of his surround- ings, or he may fall into a quiet and normal sleep. The causes which produce shock are manifold — the most important are those sensory impulses (traumatic) which affect the medullaiy centers; the next is hemorrhage. Additional causes are general anes- thesia, long-continued pain, extensive surgical operations, extreme heat and cold, certain drags, and strong psychic impressions, while various general bodily states also conduce to shock — anemia, diabetes, nephritis, sundry infections, starvation, and autointoxication (Blood- good). 1 George W. Crile, Blood-pressure in Surgery; Surgical Shock; Shock and Collapse, in Keen's Surgery', vol. i, p. 922; J. C. Bloodgood, Surgical Shock, in Brj^ant and Buck's American Practice of Surgery, vol. i, p. 463 (including a resume of Howell's article); Eugene Boise, The Nature of Shock, Amer. .Tour. Obstet., .January, 1907; J. P. L. Mummery, Lancet, April 1, 1905; W. Sheen, Lancet, June 30, 19061 SHOCK AND COLLAPSE 769 The diagnosis of shock is sufficiently obvious from the foregoing description of the symptoms. For surgeons probably the most interest- ing feature in its causation is hemorrhage, and hemorrhage and shock frequently are associated. It is not possible, however, to distinguish shock from hemorrhage under certain conditions, since shock may exist without hemorrhage, and hemorrhage may exist without shock. Hemorrhage produces, in addition to the general sj-mptoms already described, certain quite characteristic sj'mptoms — an impairment of vision, irregular tossing, frequent yawning, great thirst, nausea, and sometimes convulsions. The hemoglobin is enormously reduced, while in shock it is unaltered. In hemorrhage the attacks of syncope are recurrent; in shock such attacks do not occur. In concealed abdominal hemorrhage one may distinguish by examination evidence of accumu- lated blood in the flanks, wdiile the exhaustion is slow and progressive. Shock is generally of rapid onset, and does not suggest slow exhaustion. The treatment of shock is a subject of constant and intense interest to surgeons. It deserves careful study. Crile is probably weary of hearing himself quoted on this subject, but in these da3's his sa}-ings must fiU the page of the writer who treats of shock. However the physiologists dispute as to the cause of shock, no practical surgeon who has watched Crile's treatment of shock can doubt its efficiency. For the last seven years I have been following his advice with satisfac- tion. One endeavors: (1) To prevent further shock; (2) to support the circulation; (3) to secure physiologic rest. It is not always easy to prevent further shock, but so far as he may the surgeon must eliminate those conditions which are causing the shock, if such elimination be within his power. He must check hemor- rhage; he must reheve pain; he must remove anxiety and distress. Even in those cases of shock which have suffered their misfortune before the surgeon sees them he can assist greatly by helping to bJunt the sensibilities and to quiet apprehension. For this purpose morphin is the surgeon's sheet-anchor. There can be no doubt that mental strain and anxiety about his owoi condition will increase and prolong the patient's shock, and by just so much decrease his chances for re- coveiy. But the prevention of further shock runs into and overlaps that more important matter — the treatment of present shock, and this leads us to our second topic, stippoii of the circulation. That is a matter about which opinions have differed widely, though, fortunately for suffering humanity, surgeons are coming to agreement. We recognize two distinct divisions of this subject — two methods of supporting the circulation: (1) By external applications and posture; (2) by the administration of internal remedies. The first or mechanical method is ancient, and has alw^ays been more or less popular, though its exact manner of working only recently has become clear. By compressing the peripheral circulation of the body blood is forced into the internal organs, the heart is stimulated to increased exertion, and the nervous system is encouraged through vasomotor stimulation. At the same 49 770 MINOR SURGERY — DISEASES OF STRUCTURE time the great veins of tlie abdomen which have been drinking up the patient's blood and keeping it out of commission, as we sa}', are forced to disgorge their contents. An excellent means of exerting peripheral pressure is by tight bandaging of the limbs and trunk with broad flannel or rubber rollers. A still more effective method — a method vastly more effective in my experience — is the application of Crile's pneumatic rubber suit, which can be inflated in a minute. It is extremely interesthig, during its application, to watch the surpiising and almost instantaneous improvement in the patient's pulse. A simple and easy method of seeking the same end, but a method much less effective, is to throw the patient into a modified Trendelenburg position, by which maneuver the heart's action is relieved and the basal centers are flooded by fresh blood. At the same time keep the patient warm with hot bottles, or a hot -water bed and blankets. Saline solutions introduced into the circulation maj- be regarded either as mechanical aids or as internal remedies, but, however that P'ig. 468. — Crile's pneumatic suit (Keen's Surgery). may be, it is certain that the mere presence of an increased volume of fluid in the circulation serves for a short time to relieve shock, and is, most of all, valuable if there be hemorrhage. There are four methods of introducing saHne fluids: (1) By intravenous infusion — the injec- tion of the solution through a cannula directly into a vein, choosing preferably one of the veins of the calf or at the bend of the elbow; (2) by intra-abdominal infusion; (3) b}' rectal injections; (4) by subcu- taneous injections. As Crile remarks, it is well to give the intravenous infusion gradually, since a great amount of fluid may cause acute dilatation of an anemic heart. One should not give more than a pint, as a inile, but this amount may be repeated at frequent intervals. The intra-abdominal infusions are commonly practised in the course of abdominal operations, the opened belly being filled with salt solution and sewed up. This included solution is absorbed quickly. Rectal injections are eas}^ and comparativeh' painless, especially if given by Murphy's seeping method (proctoclysis), which I described in Chapter VIII. Subcutaneous injections (hypodermoclysis) are easily given also, SHOCK AND COLLAPSE 771 though they are painful, ^^'c inject the fhiid inuler s(Hne easily dis- tensible area of skin beneath the breasts, the loin, the thigh. Such remedies sufhce for most cases of shock, but there are times when it will seem well to supplement them by internal medication. The most efficient drug at our command is adrenalin chlorid (1: 1000), 15 minims of which may be added to 500 cc. of the saline solution; or in cases of extreme urgency we may inject into the vein a continuous infusion of 1 : 20,000 adrenalin solution at the rate of 2 cc. a minute. You shall hear much talk of sundiy drugs which clinical experience seems to have proved valuable — alcohol, ether, strychnin, digitaHs, nitroglycerin, atropin, etc. -Of these, strychnin and atropin alone are Fig. 469. — Intravenous saline infusion. A, The lower ligature is tied and the upper ligature is in place ready for tying. The valve-shaped opening in the vein is shown ready to receive the cannula. B, Flask containing the saline solution. This flask is an ordinary wash-bottle, the long glass tube of which is connected to the infusion cannula and the short glass tube to a rubber bulb with valves. By pumping air into the flask above the solution the latter is forced into the veins (Fowler). of value, and that only in appropriate and well-considered cases. We know the oft-quoted remark of Mummery: ''The administration of strychnin in shock is like beating a djdng horse; it may call forth an effort if we beat hard enough, but it hastens the end." However, there are frequent cases in which, strychnin certainly helps to tide a patient over a long, tedious operation. In the course of an extensive dissection, when the pulse iiins slowl}^ or acts with diminished force, a 4V or a ^ grain of strychnin frequently will improve the situation. Again, in that condition which we call secondary shock — a rising, feeble, or irregular pulse supervening a day or two after recovery from the primary shock — small doses of strychnin are effective — jL grain 772 MINOR SURGERY — DISEASES OF STRUCTURE every four hours. Atropin is a useful drng occasionally in shock, particularly when the skin appears moist. As Da Costa says, quoting Hare, it is a sedative to the vagus; but what makes it particularly valuable is that it acts upon the vasomotor system, combats the dilata- tion of the blood-vessels, maintains vascular tone, prevents stagnation of the blood in any vessels, and increases the amount of moving blood. In addition to the methods of treatment I have already described there is the transfusion of l)lood, which we are now finding to be of great value in cases of shock and of hemorrhage. Transfusion, an ancient and discredited operation, has been successful!}' revived in the past three years. Direct transfusion of the arterial blood of the donor into a vein of the donee — transfusion without intervening apparatus — is meeting physiologic ideals. Transfusion must usually be reserved as a last resort on account of the difficulty of securing a donor and the tediousness of the operation itself. I believe, however, that, with a wider popular understanding of its importance, and with improvements in the technic of the operation, transfusion will be frequently and suc- cessfully used in the future.^ A brief summary- of the treatment of shock, therefore, will include the following points: quiet the pain and apprehension by a hypoderaiic injection of morphin ; keep the patient warm ; employ the Trendelenburg position; bandage the limbs and abdomen, or apply the pneumatic suit; use saline infusions; add adrenalin to the infusion; if an anes- thetic is to be used, employ ether; if an operation is imperative, block the great nerve-tiiinks with intraneural injections of cocain, but, so far as possible, avoid all operations during shock; endeavor to keep the patient comfortable and tranciuil; and in extreme cases employ direct transfusion of blood — by far the most valuable measure at our command. Surgery of the Blood-vessels Surgery of the blood-vessels is no novel thing, though the furor of present-day progress might lead the unsuspecting to assume that this is a new branch of surgery. The history of the subject alone forms a fascinating chapter, and one recalls the fact that wounds of the arteries were treated for centuries by application of the actual cautery; that Hippocrates dealt inteUigently with the subject; that Galen, in the second centurj^ a. d., introduced the ligature for arteries wounded in continuity; that Pare in the sixteenth centur>' applied the ligature to arteries severed in amputations; that the ancients treated aneurysm by digital compression; that Antyllus, in the third century, devised the operation of double ligature and laying open the sac for aneurysm — an operation more recently modified by Purmann, who excised the sac; that John Hunter, in the eighteenth century, taught the operation of proximal ligation for aneurysm, and finally that Matas, of Xew Orleans, in 1903, described his extremely valuable method of aneurys- mal suture. i J. G. Mumford, The Blood in Surgerj', Ann. Surg., January, 1(110. THLEHITIS 773 Wounded arteries and aneurysms do not furnish the only material for surgery of the blood-vessels. There are diseases of the veins and capillaries — inflammations, dilatations, and vascular tumors. Let us consider shortly some of the latter lesions, and then pass in review the more important advances of latter-day surgery of the arteries. Surgery of all blood-vessels is in some respects analogous to surgery of the intestinal tract, while in other respects it differs widely. Both blood-vessels and intestines have their three coats and their moving contents, but the blood-vessels are lined with an endothelium similar to the peritoneal and meningeal serosa — a smooth, glistening membrane which, when irritated, forms ready adhesions and easily acts to cause a coagulation of the contained blood. But the contained blood is aseptic, whereas the intestinal contents are highly septic. Veins have their OM'n peculiarities as distinguished from arteries; they are thinner walled; they contain competent valves; when subject to infection, they become inflamed readily, and this inflammation spreads ciuickly to their outer coats; consequently we find the conditions known as phlebitis and periphlebitis. PHLEBITIS Phlebitis and periphlebitis, the latter being associated frequently with lymphangitis, is an inflammation of the lymphatics along the venous walls. Acute phlebitis results from injuries from childbirth, from ery- sipelas, from such superficial lesions as varicose ulcers, and from general infective processes — especially diphtheria, typhoid, pneumonia, and gonorrhea. The phlebitis of typhoid is extremely common. As a rule, phlebitis runs a short and painful course to recovery, but in the more serious cases a general pyemia may supervene, resulting in death. Chronic phlebitis is a common affair, and comprehends an inflamma- tion of a proliferating type, followed by more or less organization. Occasionally phlebitis obliterans occurs as a sequel of syphilis and other chronic infections, as well as after various operations upon the veins. The symptoms of acute phlebitis are unmistakable when the veins are superficial, but are obscure when the veins are deep. According to the situation of the veins, the skin may or may not become dark blue or dusky red or remain unaffected. The vessel, when palpable, feels cord-like. Fever comes on and rises; the inflamed area is exquisitely tender, and usually there is pain. The blood contained within the veins clots, and if this clotting be extensive, edema of the parts results. If no collateral circulation be available, the result to the parts drained by the affected veins may be extremely serious, and gangrene even may follow. The terms phlegmasia alba dolens and milk-leg describe a painful swelling of the leg due to portal, pelvic, and femoral phlebitis. One cannot readily determine the more deeply seated inflammations, but may infer their presence from the fever, the extensive tenderness, the pain, and the swelling. One sees, moreover, that deep-seated phlebitis 774 MINOR SURGERY — DISEASES OF STRUCTURE of important veins may result (|iii(kly in llie most frightful calamities. Mesenteric phlebitis may cause mesenteric ganjirene and peritonitis. Hemorrhoidal jjhlebitis nuiy extend to the higher abtlominal veins, with fatal result. Umbilical phlebitis kills newborn infants, while the sinus phlebitis associated with middle-ear disease is a common cause of death in the latter ailment. Moreover, infected thrombi dis- lodged from any vein may be carried into distant parts to set up the metastatic abscesses of a general pyemia. The treatment of phlebitis, therefore, takes on sundry and quite diverse phases. The acute surgical forms, especially phlebitis of the limbs, generally may be subdue of the leg, extreme type (Massachusetts General Hospital). bandages. The warmth is extremely agreeable, and the creolin solu- tion seems to maintain its heat for a long time. One should change these poultices every three or four hours. In all cases the septic focus from which the phlebitis originates should be treated. Otherwise no direct interference with the inflamed veins can be effectual. As an example of this, one sees "milk-leg" running an obstinate course because a septic infection of the pelvic organs has escaped observation. In the case of deep infections causing thrombophlebitis in the veins of the pelvis, the neck, or the head, the surgeon must often open the veins and turn out the clots at the same time that he attacks the localized underlj'ing disease.^ Chronic phlebitis shows its commonest forms in varicosities of the leg, the scrotum, and the anus. I have already considered the two * Professor Dr. F. Trendelenburg, A Review of Surgical Progress, Trans. Section on Surgery and Anatomy, Jour. Amer. Med. A.ssoc., 1906. rHr.KHiTis 775 latter, but it is interesting to see how, recently, varicosities of the leg have come to be treated. It seems probable that the essential pre- disposing cause is a congenital defect in the vessels or their iimerva- tion. Inmiediate causes enter in also — occupations involving long standing, and probably injuries, constipation, and child-bearing. Gradually the veins become enlarged and obvious to sight and touch, sometimes giving a sense of fulness in the leg, while there may ensue edema, pains, a constant heaviness, and painful cramps at night. The skin becomes ill nourished, glossy, eczematous, with a frequently resulting ulcer. Occasionally a vein ruptures, giving rise to a sharp hemorrhage. In Chapter XXVI, I discussed at some length the simpler treatment of varicose ulcers, and one must believe that sound and per- manent cure of these ulcers depends upon cure of the varicose veins. The treatment of varicose veins in the leg is the affair of the surgeon, but it is 'often hard to convince the sufferer of this fact. A patient comes into a physician's ofhce and shows a bunch of varicose veins. The busy physician recommends an elastic stocking, and thinks no more of the matter. That is all very well, for if the patient will wear a proper elastic stocking or, better, a well-made flannel bandage from his toes to above the knee, he will get along comfortably enough, Fig. 471. — Mayo's vein enucleator. but he will find the wearing irksome, and after a time will abandon the treatment. Then the varices will gro-w larger, and the last state of that man is actually worse than the first. For years surgeons have endeavored, by extensive dissections and excisions, radically to cure these varicosities. They were working in a septic field, and although they often cured the varix, they submitted the patient to a long and distressing convalescence. Trendelenburg has devised a useful operation — ligation and section of the internal saphenous vein in the upper portion of the thigh. Schede's operation is popular, — the so-called circumcision of the leg, — but I have come to rely almost entirely upon the ingenious procedure of C. H. Mayo — subcutaneous enucleation : seek the internal saphenous vein, ligate and cut it in Scarpa's triangle. Enucleate the distal severed portion with the long-handled ring-enucleator pictured here. With gentle force pass the instrument along the vein, tearing off the branches for six or eight inches. Then bring out the end of the instiniment through a small incision. Often the removal of this six or eight inches is enough to establish a cure, or the surgeon may repeat the performance, taking out several sections of veins throughout the length of the leg. In the calf the enucleation is somew^hat more difficult, and slight hemorrhage more frequent. For this one should elevate the leg, take out small sections of the vein at a time, and tie obstinate bleeding radicles. After 776 MIN'OH SrUGEIlY — DISEASES OF STRUCTURE the operation I di-c.s.s the leg in the (ianigee (h-essiiif;; I ilcsci'ihed in Chapter XX X' I. Aneurysmal varix is a dihitation of the v(Mns (hie to an anastomosis or connection of one of them with an artery, from which arterial blood flows into antl tlilates them, causing their pulsation. A variccsc aneurysm is usually a false aneurysm (such as formerly occurred commonly after the operation of venesection at the bend of the elbow), lying between a vein and artery and communicating with both. Rupture of a varicose vein, of an aneurysmal varix, or of a varicose aneurysm may occur, ami obstinate aijtl alarming hemorrhage may result. Simple venous hemorrhage, as from a ruptured vein in a varix of the leg, is easily controlled. It suffices usually to elevate the limb and apply a firm compression dressing for a f^ hours. If the hemorrhage persists, however, the surgeon may find it necessary to cut down upon the damaged vessel, and to tie it off above and below the damaged point . Aneurysmal varix may be treated on the principle of Matas, as I sludl explain later in this chapter. Varicose aneurysm may be excised and the wounded vessels sutured with through-and-through chromic gut stitches. ANGIOMA An angioma is a tumor composed of blood-vessels, and we group angiomata as capillary, cavernous, and arterial. Capillary angioma, or nevus, is that common form which I have already described in Chapter XX. A nevus may be excised, deeply, scored with the Paquelin cauter}-, treated by injections of boiling water, or, best of all, by carbon dioxid snow. Cavernous tumors are similar in structure to the corpus caveniosum, for the vessels become not merely dilated, but cavernous in arrange- ment. We see these tumors in the tongue, the voluntary muscles, the liver, the breast, the larynx, and under the peritoneum. They ma}' also be treated by excision, by boiling water injections, b}- electroh'sis, or by carbon dioxid snow. Arterial or plexiform angiornata are also called cirsoid aneurysms. We treat them by careful and wide dissections, often repeated, until the whole mass of affected vessels has been removed. The Arteries Surgery of the arteries finds expression in three directions — in ligation, in the treatment of aneurysm, and in the suture of arteries — the last a new and increasingly important topic. LIGATION OF ARTERIES In former times, when sepsis raged, when secondary hemorrhage was common, and hemostatic instruments were crude, the ligation of arteries was taught as one of the most important branches of surgical LIGATION OF ARTERIES 777 handicraft. To-day it is rare for the operating surgeon to seek and tie an artery in continuity, except for the treatment of aneurysm. He may occasionally expose and control temporarily a vessel with Crile's clamp in order to render bloodless a distant field of operation. Text-books of operative surgery deal extensively with the ligation of arteries. I shall content myself with describing the method of approaching and securing a few of the more important vessels. Fig. 472. — Ligation of arteries in neck, chest, and shoulder: 1, Hypoglossal nerve; 2, facial artery; 3, external carotid artery; 4, great cornu of hyoid; 5, sub- maxillary gland; 6, digastric and stylohyoid; 7, external jugular vein; 8, stemo- mastoid muscle; 9, descendens noni nerve; 10, omohyoid; 11, sternomastoid muscle; 12, vagus and recurrent laryngeal nerves; 13, internal jugular vein; 14, thyroid gland; 15, sternohyoid muscle; 16, anterior jugular vein; 17, clavicular portion of pectoralis major; 18, deltoid muscle; 19, median nerve; 20, axillary artery, first part; 21, pectoralis major muscle; 22, internal intercostal muscle; 23, pleura; 24, internal mammary artery; 25, edge of sternum; 26, pectoralis major muscle; 27, external anterior thoracic ner\'e; 28, axillary vein. The innominate artery was tied first on the living in 1818 by the distinguished New York surgeon, Valentine Mott; his patient died a month later. In 1864 A. W. Smyth, of New Orleans, tied the innom- inate, and his patient lived. Up to 1905 the innominate had been tied some thirty-five or forty times, according to Roswell Park. An excellent account of ligation of the innominate, with a complete bib- 778 MINOR SURGERY — DISEASES OF STRUCTURE liogruphy, is Herbert L. liurreU's/ who performed the operation in 1895. His patient died in the fourth month. The approved steps of the operation are as follows: Make the incision along the anterior border of the stemomastoid muscle, down to the clavicle, and then along the inner third of the bone, thus forming a flap. Divide the sternal and clavicular attachments of the muscles, and free the upper border of the sternum, taking pains to avoid the anterior jugular vein and the pneumogastric and recurrent laryngeal nerves. Burroll cvit away the end of the sternum. Find the conmion Fig. 473. — Certain nerves, vessels, and muscles of neck and shoulder (redrawn from Kocher): 1, Great auricular nerve; 2, spinal accessory nerve; 3, external jugular vein; 4, internal jugular vein; 5, hypoglossal nen-e; 6, descendens noni nerve; 7, stemomastoid muscle; 8, external carotid artery; 9, superior larj'ngeal nerve; 10, superior thyroid artery; 11, greater comu of hyoid; 12, transversalis colli artery: 13, scalenus medius muscle; 14, trapeziiis; 15, claAncular superficial cervical nerve; 16, first rib; 17, brachial plexus; 18, omohyoid; 19, platyt^ma; 20, external jugular vein; 21, phrenic nerve; 22, scalenus anterior muscle; 23, stemo- mastoid muscle; 24, subclavian artery. carotid, trace it down to the innominate, and with careful manipulation throw a silk or linen ligature about the innominate and tighten slowly the thread. If one is tying the innominate for subclavian aneurysm, he should tie the common carotid at the same time. Park suggests that, as an additional step in the technic. one might well follow Crile's method in the removal of goiters— placing the patient in a semi-upright position and applying the pneumatic suit. As the innominate is being tied, lower the patient and lessen the pneumatic pressure. 1 H. L. Burrell, Trans. Amer. Surg. Assoc, 1895. LIGATION OF ARTERIES 779 These wounds should be drained, the arm warmly wrapped and kept at rest, and pain relieved by frequent doses of morphin. The common carotid is easily reached and tied by splitting down through the sternomastoid muscle at the level of the cricoid cartilage, turning aside the deep jugular, and separating carefully the artery from its sheath before applying the ligature. The external and internal carotids are readily found also by carrying the cut a little higher, seeking the anterior border of the sterno- mastoid, and finding the origins of the two arteries at the bifurcation of the common carotid. The pulsation of all these arteries may be detected readily by the exploring finger. Fig. 474. — Ligation of axillary artery (after Park). Tie the lingual artery by turning up a crescentic flap beneath the jaw, exposing the digastric triangle, and finding the artery immediately above the digastric muscle. Tie the facial artery on the edge of the jaw, where it is felt to beat at a point half-way between the symphysis and the angle of the jaw. It is needless to detail here directions for finding the various other small arteries of the head and neck. The curious student may consult books on surgical anatomy or operative surgery. The axillary artery is divided into three portions by the pectoralis minor muscle, and is usually tied in its third portion. Approach it through an incision in the midaxilla; expose and divide the deep fascia; draw outward the coracobrachialis muscle and the musculocutaneous nerve, and detect with the finger the pulsating artery. 780 MINOR SUIUJERY- DISEASES OF STHLTTURE Find the brachial artery in the middle of the arm on the inner border of the biceps, taking;' puins to avoid tiie median nerve. Find the radial artery, high in the forearm, by opening between the supinator longus and the pronator radii teres. The artery lies beneath the supinator on a direct line with the brachial. In the middle of the forearm the radial lies along the border of the supinator longus, and it maintains the same relation at the wrist. Sir Astley Cooper performed the pioneer ligation of the abdominal aorta in IS 17, approaching the vessel through the linea alba. His patient lived forty hours. A few bokl men have followed Cooper's example. In America. Hunter McGuire, of Rich- mond, performed the oj^eration in 1S68. Experience seems to prove useless the daring experiment. All the patients have died. Ligation of the aorta has always been done for aneurysm, and it may be that the occlusion bands of Halsted, the artery suture of Matas, or electrolysis shall successfidly accom- plish that in which ligation has failed. It is not difficult to reach the aorta by an extraperitoneal route, opening down upon the peritoneum along the crest of the ilium, and turning back the peri- toneum with its contained viscera. This is an easy method, as one elimi- nates thus the difficult packing off of the intestines required when opening in the median line. By the extra- peritoneal route a wide and deep field is exposed, in which one finds readily both the aorta and the common iliac. To tie the external iliac, cut down parallel to, and just above Poupart's ligament, turn back the peritoneum, and find the artery at the midpoint between the pelvic s}'mphysis and the anterior superior spine of the ilium. The line of the femoral artery runs from the midpoint of Poupart's liga- ment to the internal tuberosity of the femur at the knee. We tie it either high at the apex of Scarpa's triangle, or in Hunter's canal beneath the long saphenous vein, near the outer edge of the sartorius muscle, between the adductor magnus and the vastus intemus muscles. The posterior tibial artery lies in a line between the middle of the popliteal space and a point midway between the internal malleolus Fig. 475. -LifTation of brachial artery. LIGATION OF ARTERIES 781 Fig. 476. — Approach to abdominal aorta and ((unmon iliac artery. Fig. 477. — Ligation of external iliac arterj', 782 MIXOK SUIUIEUY — DISEASES OF STRl.CTUKE and the tip of the heel. Iligli in tlio calf one seeks the artery by find- ing the tendon of the pkmttiris between the two heads of the gastroc- nemius, following it down and feeling the artery Ijeneath the soleus. Lower down one readily finds the artery lying in its proper line, on the flexor longus digitoi'uin. and to the inner side of its own accompanying nerve. The anterior tibial artery lies on the front of the leg, in a line drawn from a point between the head of the fibula and the outer tuberos- flp Fig. 47:>. — Ligation of femoral arten' Fip;. 479. — Ligation of ])ost('rior tibial artt'iy. ity of the tibia, to the midtUe front of the ankle-joint. One exposes it easily in this line, and finds it lying between the tibialis anticus and the common extensor of the toes. In any case, when seeking the arteries of the leg, one should flex the limb so as to render dissection the least difficult, and to bring the vessels into their easy normal relations. ANEniYSM 783 After tying iiii Jirtory in one of the extremities, close the wound snugly with stitches, elevate the linih, and strive to e([ualize its circula- tion by well-padded bandages applied ,, .» throughout its whole length. ANEURYSM Bryant ^ defines aneurysm as " either a sacculated tumor containing blood communicating with the canal of an artery and formed more or less from its walls, or a fusiform dilatation of an artery." That is a- sufficiently satisfactory definition, though every writer has his own fanc}'. There are true aneurysms and false aneurysms — when the blood is contained within all three arterial coats, or when one or more coats are ruptured and a sort of hernia of the remaining coats occurs. Again, aneurysms are fusi- form, are sacculated, are dissecting, as the cuts taken from Holmes show graphically. There are arteriovenous aneurysms, in which the lumen of an artery having become connected with that of a vein, the heart's action causes the walls of the latter to pul- sate and dilate. This form is some- times called an aneurysmal varix. And there is the varicose aneurysm also. Few studies in surgical history are more fascinating than this of aneurysm, and great writers through all time seem to have dwelt upon it as upon a matter concerning that noblest of our physical functions, the circulation of the blood, until near the end of the nineteenth century appears to have conceived of any cure for aneurysm save that involved in the extermination of the affected artery. It remained for an American surgeon, Matas, first experimenting in 1888, to show that the damaged vessel ma}' be re- paired, that the aneurysm may be eliminated directly by mechanical means, and that the offending artery may be reestablished in normal function through direct circulation past the site of the obliterated disease. The causes of aneurysm are either a previous disease of the vessel 1 Thomas Biyant, Practice of Surgery, edition of 1885. Fig. 480. — Ligation of anterior tibial arteiy (peroneal). Yet no writer from Galen's day 784 MINOR SURGERY — DISEASES OF STRUCTURE or an injury by whicli the arterial coats are Aveakened or ruptured. Syphilis or some toxemia leads to aneurysm through an endarteritis or its continuation into atheroma. In this way an atheromatous ulcer may cause a breaking down of the intima of the vessel and the escape of blood between its coats — dissecting aneurysm. Or all the coats of the vessel may stretch; or an actual traumatic tearing of the vessel may Fig. 481. — Aneurysmal varix (Bryant). allow blood to escape into the surrounding tissues, where it becomes fully encapsulated — a form of false aneurysm. Internal aneurysms — those within the cavities of the body — seldom come within the surgeon's pur- view, while external aneurysms — in the arteries of the limbs — properly come to him for treatment. The progress of the disease may be uninterrupted up to the point of rupture, or there may l:tc spontaneous checking through coagulation Fig. 482. — True aneu- rj'sm; the sac formed Ijy all the coats (Holmes). Fig. 483. — False aneu- rysm; the sac formed hy the outer coat only (Holmes). Fig. 484. — Dissecting aneur\'sm (Holmes). and the formation of a clot within the aneurysm. This clotting of the blood takes place in thin laj'ers along the walls of the aneurysm, so that on dissection of a large aneurysmal clot one finds a lamellated appear- ance. Through the formation and absorption of these layers the aneurysmal wall is streng1:hened or weakened and the final catastrophe is often more or less postponed. But a growing aneurysm always ANKURYSM 785 encroaches upon surroundino; structures. It pushes aside moval^le organs; it causes atrophy of lixed soft parts; it erodes bone. Aneurysms may be single or multiple; large or small; and no artery of the body is exempt from the disease, but the aneurysms of the large vessels of the extremities are those especially which interest the surgeon. The symptoms of aneurysm are manifold and depend largely upon the situation of the disease. The patient complains of discomfort, such as that caused by a rapidly growing encapsulated tumor, pain, indefinite aches, a sense of weight and fulness, general debility, lassitude, sometimes emaciation. He may notice the swelling if it is near the surface, and he may be distressed by the constant throbbing. The I j^ Fig. 48.'). — Aneurysm of innominate artery (Massachusetts General Hospital). surgeon makes his diag-nosis of internal aneurysm with some difficulty. He may distinguish an obscure tumor by its dulness or flatness on per- cussion. He may hear a characteristic bruit, synchronous with the cardiac systole. He may feel the expansile pulsation. If the aneu- rysm is superficial, the examiner should make his diagnosis without great difficulty— from the history, the presence of a tumor with its characteristic expansile pulsation, its bruit, and the fact that it can be emptied by pressure. Moreover, it is located in the course of one of the arterial trunks. Often there is edema of the parts with venous congestion, so extreme as to threaten or actually to cause gangrene. Should the other methods of examination fail to determine the aneu- 50 786 MINOR SURGERY — DISEASES OF STRUCTURE tysm, especially if it be internal, the x-ray picture often gives striking and conclusive evidence. The treatment of aneurysm has, until recent years, been dependent upon two principles which may be regarded as branches of one — (1) An endeavor to assist nature by favoring the fomiation of clots, and (2) the actual shutting off of the affected artery by ligature, thus caus- ing stagnation and clot fonnation. The first method must still be considered, especially when one is dealing with large internal aneurj'sms. In order to favor clotting surgeons have prescribed absolute rest in bed, a starvation diet, and cardiac sedatives; to this have been added, of recent years, more active intervention by the use of gelatin injections into the circulation, and the introdution of wire, with or without the use of electricity, into the aneurysmal sac. The last method has been moderately successful. Hobart A. Hare,^ of Philadelphia, thus treated 1 1 ij N^ ?ig. 486. — A, Operation of Antyllus; B, operation of Hunter; C, operation of Anel. cases, in all of which there was undoubted symptomatic relief, though permanent cures were not established. The method consists in passing into the aneurysm a considerable length (many feet) of a fine silver wire, and submitting it to electrolj'sis for twenty minutes or half an hour. ■ Clotting promptly occurs and the wire is left in situ. E. Lancereaux ^ has succeeded in arresting the progress of internal aneurysm by injections of gelatin serum, which he asserts t be harm- less if the serum is aseptic. The essential weakness of the lot-favor- ing methods, when applied to the great terminal arteries that they may lead to complete obliteration of the vessel — an event t be avoided. Per contra, should a channel for the blood-current remain, there is the inevitable danger of return of the disease. Halsted's metallic bands give promise of usefidness. His work is 1 Therap. Gazette, July 15, 1905. - Gaz. des Hop. ANEURYSM 787 experimental as yet. It consists in binding the affected artery with a thin, broad metallic circlet which shall limit, but not cut off, the blood- stream, and shall favor coagulation in the aneurysm beyond the band. Open division of aneurysm is a method of treatment running back into antiquity. It is known as the method of Antyllus, a surgeon of the third century a. d., and has been practised by many surgeons in modern times. It is a common-sense method, and in these days of asepsis shows a comparativel}^ Ioav mortality. The technic is simple, but is applicable to external aneurysms only. After controlling the ves- sel with a tourniquet the surgeon cuts down upon the tumor, opens it, turns out the clots, and secures by ligature its afferent and efferent vessels above and below the aneurysm. Some operators have seemed to think that, in its essential principles, this operation does not differ greatly from that of Matas. That conception is erroneous. Fig. 487. — D, Operation of Brasdor; E, operation of Wardrop. Extirpation of the sac is a modification of the AntyUian method, and has been favored by many modern surgeons. Undoubtedly, it is an improvement upon the Antyllian method, but it has its disadvantages, as I shall show. Far the most popular operation until recent years has been that of Hunter — proximal ligation of the artery at a distance above the aneurysm but below the large anastomosing vessels. John Hunter's claspi" tion, performed in 1786, was done for popliteal aneurysm. '^' ■'moral in Hunter's canal below the profunda and secured ,ult. The disadvantages and dangers of the Antyllian and Hunterian operations may not offset the advantages, but it is worth our while briefly to consider this question. The original operation of Antyllus has the advantage of occluding the artery close above the aneurysm and close below it, so that the higher anastomotic branches of the main 788 MINOR SURGERY — DISEASES OF STRUCTURE artery are not disturbed, and arc left to carry blood to the distant parts of the affected limb. At the same time, liowe\-er, as Matas has Fig. 488. — Operation to restore current in saccular aneurv'sm, first stage: Plac- ing of interrupted sutures through borders of arterial opening into aneurysm, leaving channel of vessel intact (Matas). sho-wn, this operation does not control supernumerary feeders to the aneurysm. These feeders ma^- dilate and bleed into the sac after the Fig. 489. — Operation to restore current in saccular aneurj'sm, second stage: The interrupted sutures through the borders of the arterial opening have been tied. A second tier of interrupted sutures overlying and outlying tlie first is being placed through the inner coats of the aneurj'smal sac, wliich, upon being tied, will bury the first tier and ridge up the floor of the aneurysm in the median line (Matas). operation, for we must remember that an essential step in the operation of Antyllus consists in opening and clearing out the sac. In recent ANEURYSM 789 years surgeons have substituted excision of the sac for opening it — an interesting advance in treatment; but excision of the sac involves the removal often of many small vessels, and sometimes of nerves and other structures embedded in the aneurysm's wall. Even so, the operation of Antyllus, modified by excision, has shown admirable results during the aseptic period— the operative mortality being zero, and subsequent gangrene being recorded in but 2.77 per cent, of the cases. One concludes then that extirpation constitutes an extremely valuable operation. The Hunterian operation seems easy and little formidable at a first glance. It consists in tying the affected artery Fig. 490. — Aneurysmorrhaphy : Op- eration to restore current in fusiform aneurysm. Suturing borders of open- ing and of connecting groove over a temporary rubber tube, the ends of which are seen projecting into the lumen of the vessels at either end. The interrupted form of suture is here shown (modified from Matas) . Fig. 491. — Aneurysmorrhaphy: Op- eration to restore current in fusiform aneurysm. The interrupted sutures placed in the preceding figure have been tied at the two ends, while those in the center are being held apart dur- ing the withdrawal of the rubber tube, after wliich these also are tied. Some of the second tier of sutures are shown in place, ready to be tied (modified from Matas). well above the aneurysm, but below the largest anastomotic branch of the vessel affected (for example, in the case of popliteal aneurysm one would tie the femoral artery a little below the origin of the pro- funda) . Hunter's operation has the advantage of shutting off effect- ively the blood-supply of the aneurysm in nearly all cases, but it has the disadvantage of interfering seriously with the circulation of the limb, so that even in recent years it has been followed by an operative mortality of 8.32 per cent. Many surgeons still advocate digital compression of the artery above the aneurysm, with the purpose of favoring clot-formation in the sac. I cannot recommend this procedure. It is extremely uncertain, tedi- 790 MINOR SURGERY — DISEASES OF STRUCTURE ous, for it involves often several days of treatment, painful, and is occasionally followed by gangrene. The foregoing statements represent the experience and views of surgeons up to the year 1902, when Rudolph Matas described his method of aneiiri/stnorrhaphfj} At that time numerous investigators, both in Europe and America, had demonstrated the possibility of operating upon blood-vessels by various methods of suture, so that the fact was well established that wounded vessels heal readily, and that the intima of vessels, like the peritoneum and serosa elsewhere, glues quickly to itself. Serosa to serosa and intima to in- tima are axioms. Acting upon this ac- knowledged fact, Matas showed in a remarkable series of cases that it is pos- sible to open an aneurysmal sac and to sew up the mokiiths of the arteries open- ing into it. J?.romptly intima adheres to intima, so that all the vessels concerned are obliterated. . But Matas went further, and demonstrated, by careful studies, that the preservation of the sac itself is an important element of success in these cases. He retains the sac, therefore, in- folding and crumpling it as the illustra- tions show; for the sac is vascular, and its contained arterioles are of service in preventing local necrosis. The principle of Matas is applicable to all forms of aneurysm when the aneurysm is acces- sible to operative manipulations. The sacculated aneurysm, with its single ori- fice, may be treated readily without in- terference with the main arterial trunk. The t3^pical false aneurysm ma}' be cleaned out and the damaged artery re- paired; while in the case of fusiform aneurysm, all the arterial openings may be closed without subsequent ill effects so far as present knowledge teaches. In a few selected cases of fusiform aneurysm it is possible to restore the arterial trunk by stitching up the sac so as to leave behind a channel. Progressive surgeons with enthusiasm have followed the lead of Matas. More than 80 cases of his operation have been reported with resulting cure of the aneur^^sm, preservation of the limb, and avoidance of gangrene in nearly all the cases. We are justified in asserting, therefore, that 1 Ann. Surg., February, 1903; soo also Medical News, Philadelphia, October 27, 1888, in which Matas described his first successful case, though he did not at that time propose suture as Ihe routine treatment of aneurj'sm. Pig. 492. — Aneurysmorrhaphy : Final stage of operation. The walls of the aneurysm sac and the integuments are sutured to the floor of the sac over gauze rollers, thus firmly approximat- ing the former to the latter ( Bick- ham, modified from Matas). ANEURYSM 791 Matas' operation is the operation of choice whenever its performance is possible. The standard text-books discuss sundry other methods of ligation of arteries for aneurysm — Anel's method, which consists in placing a single ligature immediately above the aneuiysm; Brasdor's method, the ligation of the artery immediately below the sac; and Warch'op's method, the ligation of the highest main branch given off below the sac. The last two methods may be our only resort in the case of certain aneurysms deeply placed and difficult of access — innominate aneurysm, for example, for which one might be forced to tie the subclavian, the common carotid, or both. When all is said, however, our operation of choice must be by Matas's method or by excision. Fig. 493. Fig. 494. Fig. 493. — Aneurysmorrhaphy: Cross-section of the parts involved in the opera- tion where the current is restored, together with the complete obliteration of the sac of the aneurysm: A, Integuments; B, aneurysmal sac; C, walls of blood-channel; D, first tier of sutures, approximating walls of blood-channel; E, second tier of sutures, approximating floor of sac over first tier; F, F, sutures through walls and into floor of aneurysm, approximating former to latter; G, suture through margin of integuments and into floor of sac, over second tier; H, restored blood-channel (modified from Matas). Fig. 494. — Aneurysmorrhaphy: Cross-section of the parts involved in the opera- tion where the blood-channel, together with the aneurysmal sac, are completely obliterated. The figures are the same as in Fig. 493, except that H here repre- sents the obliterated blood-channel (Bickham, modified from Matas). Aneurysmal varix, if treated at all, may be cured by applying the principle of Matas — laying open the distended vein and suturing from within the anastomotic opening.^ In any case of operation for any form of aneurysm the surgeon should see to it that the patient has careful after-treatment. The wound should be dressed with abundant, elastic compression dressings; the involved limb should be bandaged throughout its entire length; should be well supported, and should be kept at rest for two or three weeks or until satisfactory collateral anastomosis has been fully estab- lished. If all goes well, the patient should be able to get about and use the arm or leg freely at the end of a month. 1 Warren S. Bickham, Ann. Surg., 1904, vol. xxxix, p. 767. 792 MINOR SURGERY— DISEASES OF STRUCTURE SUTURE OF THE BLOOD-VESSELS Suture of the Ijlood-vessels is a subject which suggests itself at once in connection with .Matas's treatment of aneurysm. I have aheady dealt with suture of the heart in Chapter X\II1, but recently a new branch of surgery has been developed in the suture of the blood-vessels (angiorrhaphy).' One may not dwell profitably in this place upon the great literature which has grown up about the subject. Suffice it to say that l)eginning with Lambert's first pin suture of a wounded artery in 1759— an operation forgotten for nearly one hunderd and fifty years — a large number of well-known investigators have worked at the suture problem, especially within recent years. Lateral arterior- rhaphy, the sewing up of a wound in the side of an artery, is now a well- recognized procedure. One may use fine silk or chromicized catgut and sew up the rent with through-and-through stitches. Wounded veins may be treated in the same fashion. Circular arteriorrhaphy, or end-to-end anastomosis, is a more difficult but far m(jre interesting operation. Experiments to this end have been numerous, but the more popular methods now in vogue among us are those of J. B. Murphy, by invagination, and of Alexis Carrel and Charles C. Guthrie, by direct marginal suture. Carrel's' method is likely to prove the more popular. The experimental work has already demonstrated the possibility of transplanting organs, limbs, and heads even, and gives promise of developing into a great and valuable new field of surgery. Surgery of the Lymphatic System Of late 5'ears writers have been telling us that the lymphatic system is becoming increasingly important to the surgeon. I doubt how that may be. The lymphatic system has always been important — probably never more so than in the old days of sepsis, when operation W'ounds were continually infected, with a complicating extension of inflammation through the neighboring lymphatic vessels. Surgery of the lymphatic system deals wath the lymph-channels and with the lymph-nodes. The old term "lymph-gland" is a mis- nomer. The nodes which occur frequently through the lymphatic system are not glands. They are not secretory organs, but rather filters and reservoirs. The lymph-channels are subject to two important types of affection — occlusions and inflammations. The lymph-nodes also are subject to two main varieties of affections — new-growths and inflammations, in which respect, indeed, they resemble true glands, though the spread of disease through the lymphatic system is pecu- liarly active. 1 Rudolph Matas, The Suture in tlie Surgery of the Vascular System, 1906; also Keen's Surgery, vol. v. 2 Alexis Carrel, formerly of Lyons, now at the Rockefeller Institute, New York City. SURGERY OF THE LYMPHATIC SYSTEM 793 Here is Fischer's classification of these aiJnicnts: AFFECTIONS OF THE LYMPH-VESSELS: L Acute inflammation of the lym])li-vessels. 2. Chronic, non-specific infianmiation of the lymph-vessels. 3. Tuberculosis of the lymph-vessels. 4. Lymphangitis syphihtica. 5. Carcinosis of the lymph-vessels. 6. Dilatation of the lymph-vessels. AFFECTIONS OF THE LYMPH-NODES: 1. Acute inflammation of the lymph-nodes. 2. Chronic, non-specific inflammations of the lymph-nodes. 3. Tuberculosis of the lymph-nodes. 4. Syphilis of the lymph-nodes. 5. Primaiy tumors of the lymph-nodes, 6. Secondary- tvmiors of the lymph-nodes. 7. Lymphadenocele. Such a classification is admirable, so far as it goes, but it takes no account of those diseases resulting in obstruction of the lymph-channels, with secondary' hj-pertrophy of the adjacent tissues, frequently due to the organisms, filarise, and resulting in the diseases of which lym- phangiectasis and elephantiasis are the most conspicuous. A few words upon the physiology of the lymphatic system. We recall that there are four different types of lymph, according to Hall : L Tissue lymph, which fills the intercellular spaces throughout the body. 2. Circulating lymph, which passes through the lymph capillaries into the circulatory system by the way of the thoracic duct. 3. Chyle, the peculiar circulating lymph of the intestinal tract, which carries nutritive material. 4. Serous lymph — the contents of the serous cavities. All these fluids, except chyle, contain at least 95 per cent, of water and nearly -1 per cent, of proteids. To quote the excellent statement of Roswell Park, the lymph is the only fluid which comes into contact with all the living cells of the body. Blood, on the other hand, comes into contact with the endo- thehal ceUs only of the vessels, and with those cells in the splenic pulp, and perhaps other localities which have to do with its elaboration. These are but a minute proportion of the total cells of the body. All the other body cells receive their nutrition and oxygen from the lymph, which takes its supply from the blood. Moreover, nearly all the waste materials of the body are emptied into the lymphatic system, and thence into the blood. Thus one sees that the lymph is the almost universal vehicle of exchaage between blood and tissues through the body, and that its role in the economy is of the highest significance and importance. The larger lymph-streams have been sho-^Ti to flow in thin-walled vessels with valves, but the great bulk of lymph in the tissues circulates freely in spaces, so called, among the tissue-cells. 794 MINOR SURGERY — DISEASES OF STRUCTURE Let US first survey briefly and hastily the affections of the lymph- channels. In view of what I have said regarding the inevitable presence of lymph-channels and a lymph circulation everywhere throughout the body, we realize how grave may be the infection of these channels. LYMPHANGITIS Acute lymphangitis is due commonly to an infection introduced from without, although it may arise in connection with some internal or systemic derangement — for example, typhoid fever or puerperal Fig. 495.— This illustration shows the application of the elastic bandage around the arm, with its end tucked under (Meyer and Schmieden). septicemia. In the hospital wards and in general practice you shall find lymphangitis of the arm by far the most common form of lymphan- gitis. The finger of the victim is the seat of a small punctured wound often; thence organisms promptly enter into the lymph circulation; they propagate and spread with amazing facility, so that frequently the main lymph-channels of the arm, even to the axilla, are seen to be defined as red, tender lines, following especially the course of the larger blood-vessels. One or two nodes above the external condyle may check for a time the process, but quickly it spreads upward to the more LYMPHANGITIS 795 numerous axillary nodes. If the disease runs unchecked, there may- result thrombi, infection of the adjacent tissues, a general breaking down of the parts, and extensive abscess formation through the efforts of nature to combat the poison. As regards routine treatment, this is both local and general. Vaccine therapy always should be employed whenever vaccines can be secured but, unfortunately, in the practice of most men, vaccines, except stock aureus vaccines, are not available. It remains, therefore, to accept the best local and general treatment, aside from the vaccine treatment. The patient should be stimulated and sustained by tonics of strychnin, iron, and whisky ; his bowels and kidneys should be kept Fig. 496. — Zander room for mechanical therapeutics at the Massachusetts General Hospital (formerly the old Bigelow amphitheater). active — a factor never to be neglected; he should be kept in the open air; should receive abundant simple nourishment; and, above all things, should not be forced to depend upon his own efforts for any- thing; he should be nursed. Good local treatment consists in the encouragement of stasis hyperemia by Bier's method;^ the opening of all collections of pus; and careful bandaging and support of the arm, as described in Chapter XXVI. We recognize two forms of lymphangitis: the reticular, in which a minute network of vessels is affected, giving to the skin an erysipeloid appearance; and the tubular, which affects the larger vessels only. ^ I refer the reader to the valuable publication of Willy Meyer and Victor Schmie- den on Bier's Hyperemic Treatment, pubUshed in 1908. 796 MINOR SURGERY — DISEASES OF STRUCTTRE Commonly, the two foi-nis coexist, while the treatment is much the .same in lioth. \\'riters discuss antiseptic lotions in the treatment of lymphangitis. Hot, frequently applied lotions are extremely comforting, and are vahiable adjuncts to Bier's treatment. They act by increasing the hyperemia of the parts, but there is no reason to suppose that their antiseptic equalities are advantageous. I employ, as a rule, large poultices of creoHn (1: 200), changed every two hours. Chronic lymphangitis is a rather uncommon outcome of such an infection as I have described. The condition is annoying rather than dangerous. The lymph-channels are obstructed; the tissues may or may not become thickened and brawny, while interference with the function of the parts is more or less likely. The patient should be given an out-of-doors Ufe, good food, and exercise, and if possible should have daily massage, or the Zander treatment, over the affected region. Tuberculosis of the lymph-vessels is always associated with tuber- culosis of the lymph-nodes. The vessels become somewhat thickened and tender, but tuberculosis of the lymph-channels alone is relatively insignificant from the point of view of both prognosis and treatment. In Chapter XXII, I have already discussed tuberculosis of the lymph- channels and nodes of the neck. The disease there shows us the typical points of lymphatic tuberculosis. Syphilitic lymphangitis exists. Carcinosis of the lymph-vessels con- cerns us, and I shall have something to say on this subject in the chapter on Tumors (Chapter XXVIII). LYMPHANGIOMA, LYMPH VARICES, LYMPHANGIECTASIS, AND LYMPHADENOCELE These are terms used variously to denote obstruction and dilata- tion of lymph-channels. Tumors and enlargements result from obstruc- tion; usually they are congenital, sometimes they are acquired. The growths progress rapidly; the channels are usually filled with a trans- lucent, milky fluid, probably identical with normal lymph. These tumors are benign, bvit from their size they may cause distress. Lymphangiomata spring from lymph-channels; they consist of the dilated channels, bound together with a framework of connective tissue. The resulting tumor resembles the common hematogenous angioma. Lymph varices resemble closely ordinar^^ varices. Ljmaphangiectasis also is a term applied to collections of dilated lymph-vessels — dilated from obstniction. The causes of such obstruc- tions are numerous and the resulting conditions manifold. Common causes are cicatrices, tumors, and ascites, while the most frequent cause leading to chronic obstruction is the presence of the Filaria san- guinis communis. In tropical countries especially this chronic lym- phatic obstiTJction, known as filariasis, is of extreme importance. The jilarium is a parasitic worai which Hves in the lymphatics and LYMPHANGIOMA, LYMPH VARICES, LYMPHANGIECTASIS 797 blood-vessels of man. It gives off an enormous number of ova, from ^^•hit•ll embryos quickly develop and circulate in the blood. They may be found readily, especially at night, for during the day they are confined to the abdomen and thoi-acic vessels. They are active; their length is about 4 nun.; their diameter that of a red blood-corpuscle. Certain mosquitos carry them. The sympto7vs of JUariasis are not necessarily severe, but the patient may be a life-long sufferer, and may have to endure great and con- tinued discomfort. Swellings appear in various parts of the body — l}'mph tumors. The groin in particular is affected, and there follow Fig. 497.— Elephantiasis (^INIassachusetts General Hospital). various forms of elephantiasis, especially of the scrotum, the "vailva, and the legs. Patients may have chills and fever, and are especially subject to erysipelas and other concurrent infections. This elephan- tiasis is due, as a rule, to the same causes which produce the swelling in lymphadenocele, — to the plugging of the lymph-vessels, — ^but the disease is local, especially in the skin and subcutaneous tissues, where there is a chronic hyperplasia. We make the diagTiosis sure by finding filaria in the blood. The treatment of fdariasis is still unsatisfactory. We have no specific drug which can destroy the parasite. Lacking that, our best 798 MINOR SURGERY — DISEASES OF STRUCTURE course is to remove the patient, if possible, from the afflicted region ; and, by surgical measures, to remove the tumor growths so far as possible. All this is far from satisfactory, and the surgery is far from brilliant. Our hope for future treatment lies in the discovery of a proper chemical antidote. LYMPHADENITIS Adenitis, or acute inflammation of the lymph-nodes, follows such an infection as I have described in speaking of lymphangitis. We think of the lymph-nodes as barriers or filters. They hold up the advancing organisms and are themselves in turn infected and destroyed. There is good reason to believe that new lymph-nodes may develop after the destruction of the old ones. The inflammation and swelling of certain nodes are recognized by surgeons as suggesting certain definite sites of infection. For example, inflammation of the nodes in Scarpa's triangle suggests an initial lesion in the foot; inflammation of the nodes along Poupart's ligament suggests a lesion of the genitalia; inflammation of the nodes behind the elbow suggests a lesion of the hand; inflammation of the nodes in the axilla, a lesion of the hand, arm, or breast; an abscess immediately below the mastoid suggests an infection of the scalp, often from head-lice; while inflamed nodes in the anterior triangle of the neck point to damage about the mouth, lips, tongue, throat, and face. The symptoms of acute inflammation of the lymph-nodes are the familiar symptoms of developing abscess, to which, from time immemorial, surgeons have attached the tenns, dolor, calor, rubor, tumor, and functio Icesa. The pain is due to tension upon the delicate nerve terminals; the heat is due to the increased blood-supply which nature throws into the part in her endeavor to meet the bacterial invasion; the rubor, or redness, may or may not be apparent, depending on the nearness of the abscess to the skin; the swelling or tumor is always present; while impairment of function is due to the pain of movement rather than to any actual destruction of the nerves or muscles. The treatment of these infected lymph-nodes (infected by P30- genic organisms) can be nothing short of free incision, with the evacua- tion of the broken-down lymph-structures ; free crucial incision, because a straight incision may glue up and not allow the wound to heal from the bottom, as it should. Sometimes the abscess formation in a node may be prevented if the source of infection be eliminated promptly by treating the infected node with poultices, with lead iodid ointment (10 per cent.) ; or with Bier's cupping-glasses.^ As a rule, however, these infected lymph- nodes should be opened, thoroughly cleansed, packed lightly with 1 I do not agree with those writers who see no advantage in external applica- tions. Nearly twenty-five years of experience in large hospital clinics convinces me that external apphcations frequently are not only of value in subduing early infections, but are of extreme comfort to suffering patients. There are other remedies. hodgkin's disease 799 gauze, and the parts immobilized (as I have described in Chapter XXVI) with abundant, absorbent, elastic-compression dressings. Chronic lymphadenitis may develop out of an acute lymphaden- itis, or may be slowly progressive from the start. The condition is common enough, and is not always noteworthy. A great many per- sons have, in various parts of the body, small, slightly enlarged lymph- nodes which never trouble them. Should these nodes become trouble- some, they may be removed easily. Tuberculous lymph-nodes, on the other hand, have marked and distinct dangers. Tuberculous lymph-nodes of the neck give rise to that condition known in the old days as scrofula, a term long since abandoned. I have already discussed tuberculous lymphadenitis of the neck in Chapter XXII, and merely remind the reader here that, through the cavity of the mouth and through the tonsils, tuberculous organisms can enter the lymph circulation. For this reason some 90 per cent, of all tuberculous lymph-nodes are in the neck. We treat the disease in reasonably robust persons by enjoining an out-of-doors life. If the infection be progressive, however, we must excise all the affected parts. HODGKIN'S DISEASE Hodgkin's disease is quite another ailment than ordinary lymph- adenitis, and it has been described under many names, such as adenia, adenoid disease, adenolymphoma, splenic anemia, etc. In a monograph before me I find 31 terms used to indicate Hodgkin's disease, yet the exact nature of the ailment is not clear to us. Some authors maintain that it is tuberculous; others, that it arises from sundry infecting organisms not yet identified; others that it is sarcomatous. Hodgkin's disease manifests itself in a great swelling of the lymph-nodes and of the spleen. The disease is not common, and the best present author- ity asserts that it is not to be confounded with splenic anemia. The enlargement of the nodes depends upon an overgrowth of the cells and of the lymphocytes — hence the term, lymphocystomata; while many of the cases are characterized by histologic changes resembling a chronic inflammatory process with proliferation of endothelial and reticular cells, the formation of giant-cells, and the presence of many eosinophiles with a progressive fibrosis. As Warthin states,^ the clinical complex of Hodgkin's disease has at present no pathologic entity, but may be produced by a variety of conditions quite different in nature. We make the diagnosis by the aid of the microscope, and limit the term Hodgkin's disease to that ailment in which the enlarged lymph- nodes are of a chronic imflammatory type. The clinical course is somewhat as follows: The patient is com- monly a young man in good health, who observes a swelling on the side of his neck. This enlarges, and similar swellings appear elsewhere — on the other side of the neck, in the axillae, the groins, and the great body cavities. The tumors, if of rapid growth, are soft; if of slo^W * Osier's Modern Medicine, vol. iv, p. 829. 800 MINOR SURGERY — DISEASES OF STRUCTURE growth, thoy are hard. The nodes, at first discrete, eventuall}' merge. Deformity may be great. The spleen may become enormous. The patient experiences no pain or soreness. Suppuration does not occur, but there develops extreme anemia, weakness, emaciation, cachexia. There is slight occasional fever, there is progressive dyspnea, loss of appetite, indigestion, headache, and dizziness. The limbs become edematous; a general anasarca develops, the patient becomes progres- sively more feeble, and dies at last of exhaustion. The hhod examination shows a diminution of all the peculiar con- stituents of the blood, but there is no marked disproportion between the red and the white corpuscles. The hemoglobin may be very low. Cultures from the blood and nodes are sterile. The treatment of Hodgkin's disease, after such a description, is obviously unsatisfactory. We know no specific remedy. Surgery, or rather the knife, can do no more than palliate the symptoms, and occa- . -J, r'>| /7-..f<.-«3/»//VATl Fig. 504. — A diagrammatic representation of a horizontal section through the liead of the humerus to indicate the lateral extent of tlie l)urRa, and the necessity for its existence to allow the greater tuberosity to rotate beneath the deltoid. Notice also how the tendon of the subscapularis is stretched around the head in the opposite direction in external rotation. This stretching occurs not in the tendons themselves, which are very short, but in the muscles which, by their construction, take up the slack of the capsule of the joint. In fact, the capsule of the joint is really made up of the tendons and muscular heUies of these short rotators. It can easily l)e imagined how a simultaneous spasm of these muscles would lock the joint, for in the normal motion one must relax as the otlier contracts. Notice also the cross-section of the coracobrachialis and the necessity for the subcoracoid bursa which lies between it and the subscapularis. Since the two muscles work at right angles to one another the bursa is indispensable (E. A. Codman). See Fig. 504 (E. A Codman). THE BURSyE 811 Fig. 506. — Dotted line showing incision used for demonstration of the bursa. For en- largement see Fig. 507 (E. A. Codman). Fig. 507. — Illustrates the appearance when an incision is made into the normal bursa (E. A. Codman). sists for more than ten days, the bursa should be opened, evacuated, wiped out with 95 per cent, carbolic acid, followed by 70 per cent. 812 MIXOU SURGERY — DISEASES OF STRUCTURE alcohol, and closed securely without drainage. If pain and impaired function follow the subsidence of distention, the sur' dismay. Malignant degeneration of scars and ulcers occurs in various parts of the body. Marjolin described the condition half a century ago, and Da Costa wrote of it again in 1903 (Marjolin's ulcer). The term is applied to chronic ulcers which have undergone malignant changes. Cicatricial tissue also may undergo similar changes. Lupus and syphilis Fig. 509. — Keloid (Massachusetts General Hospital). are among the etiologic factors. The ulcer takes on malignant charac- teristics about its margins, and these malignant changes, when once started, may progress rapidly. The ulcer's edges become hard and elevated ; the granulations large and hemorrhagic ; there is often great pain and a fine bloody discharge; the adjoining h^mph-nodes become involved, and the ulcer runs the characteristic malignant course. The treatment is obvious — a prompt and wide excision. 52 CHAPTER XXVIII TUMORS In this chapter I propose to discuss briefly the subject of tumors, although by so doing I must viohite the promise in my introduction that I would not deal in this work with matters of general pathology. Tumors, however, belong esentially to surgery as distinguished from medicine. Except when hopeless — and who may say what is hopeless? — tumors have no place in medical wards or under the care of the internist. A distinguished American surgeon recently said to me: " I visited one of your famous hospitals and went through the medical wards with the visiting physician. He showed to me a number of patients whose ailment was cancer of the stomach. What were cases of cancer of the stomach doing in the wards of an internist? He could not cure them." Such is the radical surgeon's view — and it is a view which is gaining new adherents daily. The term tumor is a clinical rather than a proper pathologic term. It signifies a swelling merely; and, literally used, might well be applied to tuberculous joints or to ascites. Commonly, the physician means by the term tumor a solid new-growth — a neoplasm. Roswell Park's definition is: '■ "A tumor is a new formation, not of inflammatory origin, characterized by more or less conformity to the tissue in which it has its origin, and having no physiologic function." The terms neoplasm and new-groivth are interchangeable. We speak of benign tumors and of malignant tumors. A benign tumor is a new-growth which increases by the proliferation of its own intrinsic elements without destroying neighboring structures. It remains generally confined to its own capsule and causes no known hematogenous changes. A malignant tumor is a new-growth which spreads unconfined, and destroys neighboring structures as it advances. It produces remote metastases; it is associated usually with hemolytic changes, and it kills the patient. Benign tumors may and sometimes do destroy life, but, as Bland- Sutton puts it : " The baneful effects of innocent tumors depend entirely upon their environment, but malignant tumors destroy life, whatever their situation." Benign tumors may become transformed into malignant tumors, while there are inteiinediate varieties which cannot be assigned to either group. Uterine myomata may be multiple — one of these asso- ciated myomata may require a saw to divide it; another may be as soft as a ripe fig; while a third ma}^ be as viscous as jelly. One of these ^ Roswell Park, Modern Surgery, p. 255. 818 CAUSATION OF TUMORS 819 tumors may remain innocent, while another may go on with changes of structure until it becomes definitely a carcinoma. CLASSIFICATION The classification of tumors made by authors is various, and at times surprishig. ^\e know little as yet of the etiology of tumors, and are unable, therefore, to classify them on an etiologic basis. We group them accordingly, on a basis of histology, assigning to them names which designate the more important elements in their stmcture. In general terms we can divide tumors into four groups — cysts, dermoids, connective-tissue tumors, and epithelial tumors. Such a classi- fication is doubtless too limited for convenient practice, though it is essentially that of both Bland-Sutton and Roswell Park; while Nicholls,^ drawing largely on the work of Adami, gives an extremely complicated classification, based largely on the differentiation between the primary cell-layers in the fetus — the lepidic or lining membrane tissues; and the hylic or pidp tissues. Adami's classification has certain elements of great value, as it enables us to distinguish, for example, the endo- thelial from the epithelial growths. In this brief treatise, however, I shall employ a more familiar, even though unsatisfactory, classification, as follows: (1) Cysts; (2) dermoids; (3) teratomata; (4) connective-tissue tumors; (5) neuromata; (6) epithelial tumors; (7) corium epitheliomata; (8) odontomata. CAUSATION OF TUMORS The causation of tumors is one of the burning questions of medical science— a question so intricate, so hotly debated, and so far from settlement that I shall attempt no special expression of opinion regarding it in this brief and elementary writing. It is well, however, that the general reader should have some notion of the opinions and clash of authorities. The traumatic cause of new-growths was accepted without question until the last generation. To-day traumatism as a cause of tumors is regarded variously by sound observers. Those who take the nega- tive side of the argument assert that we have no positive experimental evidence that traumatism causes new-growths — and by this we mean commonly malig-nant disease. They remind us that every patient who suffers from malignant disease can point to some antecedent injury to the part affected ; but, these critics say, what person lives who cannot recall some slight injury to every region of his body? Moreover, experimenters have been unable to produce neoplasms by purposeful damage to any structure. Observe, however, that by traumatism we understand not only immediate and obvious tissue damage by blows or other irritating forces, but structural disturbances, gradually pro- duced through long-continued sfight pathologic actions, w^hich at first may not have been seriously regarded. In this latter class of trauma- 1 Bryanl and Buck, American Practice of Surgery, vol. i, p. 294. 820 MINOR SURGERY — DISEASES OF STRUCTURE tisms we include cluniai2;e to the uterus by child-bearing; damage to the stomach by hypcrchlorhydria, leading to ulcer formation; damage to the gall-bladder by inflammatory affections leading to calculus formation; damage to the breast through lactation; and damage to the lip, in men, through the habit of pipe-smoking — a cause of damage as rarely operative in women as is e})ithelioma of the lip in women. In view of such facts many surgeons have returned to the view that traumatism, especially long-continued traumatism, is a potent element in the causation of malignant disease. Cohnheim's enihryonal hypothesis has been, and still is, a favorite explanation of tumor formation in a certain number of cases. He founds his hypothesis on the anomalous embryonic arrangements of certain cells, and asserts that in the early stages of embryonal develop- ment there are produced more cells than are necessary for the consti- tution of a certain part, so that a number of cells i-emain superfluous. Large groups of superfluous cells may exist, producing superfluous organs and limbs even. In other cases certain small groups of cells, hitherto unrecognized, may be roused into activity and pi'oduce a neoplasm. Heredity was regarded for centuries as an important element in tumor formation, but we have little reliable evidence that it is im- portant. The parasitic theory of tumor formation has become popular within recent years. New evidence in its favor is being accumulated and new arguments are being advanced. The controversy is now with us, but I feel that it is no part of this writing to deal with a ciuestion so recent, of a literature so voluminous, and so far from solution. CYSTS A cyst is a sac distended with fluid. The sac may contain a single cavity or it may be divided into countless compartments. Cysts result from the abundant dilatation of preexisting cavities or tubules. There are retention cysts, tubidocysts, hydroceles or distention cysts, and gland cysts. A familiar form of retention cyst is Jiydronephrosis due to ureteral obstruction with a consequent dilatation of the renal peh'is. Tubulocysts are cystic dilatations of certain functionless ducts and obsolete canals. Bland-Sutton describes seven species of tubalo- cysts: (1) Cysts of the vitello-intestinal duct; (2) cysts of the urachus, (3) paroophoronic cysts; (4) parovarian cj^sts; (5) cystic disease of the testes; (6) cysts of Gartner's duct; (7) cysts of IMiiller's duct. Several of these forms are embryonal ; several of them are so extremely rare as to be surgical curiosities. I have already described in Chapter XI the more familiar forms of cysts connected with the female genera- tive organs; and in Chapter XV, the analogous cysts of the male organs.* * I refer the reader who seeks more detailed knowledge to Bland-Sutton's exhaus- tive article in Keen's Surgery, vol. i, p. 863, and to Albert G. Nicholls' essay in American Practice of Surgery, vol. i, p. 291. CYSTS 821 Nicholls reminds us of the important distinction between cysts and cystomula. In general teims we may define a cyst as a patliologic cavity containing Iluid; but av(> do not think of new formed tissue as a cyst of this type. A cystotna is a true neoplasm, resulting from the proliferation of a matrix that tends to form cavities. Cysts of the vitello-intestinal duct make themselves evident com- monly in small, cherry-like tumors, red, soft, and velvety, connected with the navel by slender pedicles. These tumors are derived from the intestinal canal, as their histology shows. They are easily removed with the cautery. Fig. 510. — Cyst of the mesentery (Vander Veer). Fie 511.— Congenital cyst of the pelvis (Ahlfeld). Cysts of the urachus or cord passing from the urinary bladder to the naval are quite rare. They are difficult of diagnosis also, and suggest a distended bladder, rather than any of the more comrnon forms of cysts. These cysts may be easily removed and the communica- tion with the bladder closed through an abdominal section. Echinococcus cysts ((Tania echinococcus) are due to an mtestmal worm whose normal habitat is the dog. The worm is about 4 mm. m length and consists of four segments, of which the fourth and largest only becomes mature. These creatures produce enormous quantities of eo-gs which may be conveyed with food to the viscera of man. ihere they mature and the resulting embryos pass into the blood-vessels and 822 MINOR SURGERY — DISEASES OF STRUCTURE are conveyed to various organs, especially the liver. In the organs of the afflicted person the embryos becomes transformed into cysts, commonly called hydatid cysts} Each cyst-wall has a peculiar struc- ture—an external elastic layer, and an inner layer of granular matter, cells, muscle tissue, and a vascular system. These cysts are held in a fibrous capsule, and are maintained within it in a fluid medium. If one removes this fluid by tapping, the external capsule, or so-called "mother cyst," at once collapses, while the fluid withdrawn is found to contain numerous small ''daughter cysts,"— suggesting grape-skins,-- hooklets, and various other constituents, such as sodium chlorid, succinic acid, and occasionally leucin, ty rosin, and sugar. Fig. 512. — Portion of a liver wliich weighed 25 pounds tl:oroughly infested with echinococcus cysts (Bland-8utton). Echinococpus disease is peculiar especially to certain latitudes, and is endemic in Iceland. A patient from Iceland, who is the victim of a tumor, should always be suspected of echinococcus disease. The syr7iptoms and diagnosis of echinococcus disease depend entirely upon the location of the disease, whether in the liver, kidney, brain, or elsewhere. In general terms, we find that the damage caused by the disease is in direct proportion to the size of the cyst and to its interfer- ence with the function of the organ in w^hich it lies. As a general rule, the diagnosis is made by accident in the course of an operation, the 1 The word "hydatid" means properly an encysted re.s/r/e. It is not ai)plied to echinococcus disease alone, as many think. CYSTS 823 surgeon having explored the affected region with the purpose of evacuat- ing pus or I'enioving a tumor. As to the trcattnent of this disease, I have hinted at it in the fore- going i)aragraph. In most cases, owing to the deep site of the tumor Fig. 513. — An echinococcus cyst, showing the peculiar lamination of its walls (Leuckart). and its relation to the vital organs, it cannot be removed entire, but must be subjected to drainage and to long-continued irrigation with such aseptic fluids as potassium permanganate or weak bichlorid solu- tion. Rarely, the surgeon may be able completely to enucleate the "mother cyst." As for hydrocele, I have already discussed specific instances of the disease, such as hydrocele of the tunica xaginalis, hydrocele of the cord, eic, hydrocele of the neck is an ancient term used to describe cystic collections of congenital origin due to dilatation of the branchial ducts. Neck hydrocele is far from common, and is generally mistaken for a deep abscess or for masses of tuberculous glands. Ranula is the common example of a gland cyst. It is a retention cyst, due to obstruction of the sub- maxillary or sublingual ducts. There are pseudocysts which properly are distended diverticula, such as I have already described as spring- ing from the esophagus or intestine. There are so-called neural cysts; for example, hydro- cephalus smd spina bifida. In other chapters of this work I have dealt with the various characteristics of special forms of cysts. It is needless here to repeat those descriptions beyond re- minding the student that in most cases cysts are readih' amenable to operative treatment, but that permanent cure depends upon the de- struction and removal of the cyst-wall, and not upon its simple drain- age— an ancient, easy, and fatuous procedure. X.I2 Fig. 514.— Taenia echino- coccus (Leuck- art). 824 MINOR SURGERY — DISEASES OF STRICTURE DERMOIDS AND TERATOMATA Dermoids and teratomata '■ are tumors often confounded with each other by the thoughtless speaker. Indeed, they are conditions of distinctly different origin. Dermoids are cysts or tumors containing tissues and ap})ontlages which are developed from the epiblast. .\ sim])le form of dermoid is a cyst whose interior is lined with skin bearing hair and sebaceous glands. The cavity of such a cyst is usually filled with a mixed thick lifjuid made up of fat, water, cholesterin, and growing hairs. A common location of dermoids is in the median line and in the region of the embryonic fissures. We see dermoids of the back associated with spina bifida and dermoids over the sternum. There are dermoids of the scalp, which are frequently called wens, and dermoids of the dura '^ff^' Fig. 515. — Solid dermoid tumor escuiiiiig from the pelvis (Park). mater even. Dermoid cysts are found most commonly in the ovary and may there attain a large size. Sometimes these forms of tumor may degenerate into sarcomata, or may even develop as cancers. In their ordinary form, and when non-malignant, dermoid cysts cause such symptoms as we should expect from an}' other benign tumor, encroaching upon organs and interfering with their functions. The treatment is radical extirpation, and the extirpation must be thorough indeed, for if any of the epithelial lining of the cyst be left, a new tumor of similar type is likely to form. Teratomata are structures far more complicated than are dermoids. They may contain mere fragments of embryonic tissue, or they may contain portions of jaws, teeth, limbs, and even the trunk of a partially ^ Dermoid, from derma, skin; teratoma, from icrata, monstrosity. DERMOIDS AND TERATOMATA 825 formed embryo. The so-called "double monsters," museum curiosi- ties, properly are teratomata. Bland-Sutton's definition is: "A teratoma is an irregular con- glomerate mass containing the tissues and fragments of viscera belong- ing to a suppressed fetus, attached to an otherwise normal individual. It is a significant fact that external teratomata are found almost ex- clusively in connection with the vertebral column and skull." As Koswell Park states : " The presence of supernumerary members is largely connected with what is called dichotoryiy, alluding thereby to cleavage either at the anterior or posterior end of the developing embryo. When the whole embryonic axis divides, twins may be pro- duced, but should the cleavage be partial, we may have a monster with two heads, if it be anterior; or one with three or more limbs, if it be posterior." Fig. 516. — A postrectal dermoid with hair and a tooth (Bland-Sutton). More commonly, however, the surgeon finds teratomata as tumors within the abdomen or thorax, or upon the face or neck, and these tumors may contain a few vertebrae or processes resembling fingers or portions of viscera. Such a tumor may be found in the larynx also, hanging by a small pedicle, or in the sacral or coccygeal regions. Teratomata, like dermoids, may take on malignant changes, which condition seems to lend strong support to Cohnheim's hypothesis re- garding the origin of tumors. The symptoms and the treatment of teratomata differ in no obvious degree from the symptoms and treatment of dermoids, as I have de- scribed them. 826 MINOR SURGERY — DISEASES OF STRUCTURE TUMORS OF THE CONNECTIVE-TISSUE TYPE Tumors of the connective-tissue type constitute a large class — probably a majority — of all tumors; and we divide them into two main groups — the benign and the malignant. A\'e need not here consider in detail the structure and characteristics of all these growths, but we may well name them severally, and glance at those factors in their make-up and their life history which are of special interest to surgeons. A lipoma is a tumor composed of fat, and is one of the most common of new-growths. There are encapsulated lipomata and diffuse lipomata, the former being surrounded with a sheath of fibrous tissue, while the Fig. 517. — Lipoma uf shoulder. Removed. Local ane.stliesia (author's case). latter e.xtend in all directions without a well-marked fibrous limit. Encapsulated lipomata are found in all parts of the body — under the skin, the serosa, and the mucosa; within the joints; and beneath the peritoneum. These encapsidated lipomata are more or less intimately adherent to their fibrous sheaths. Sometimes one may be shelled readily out of its sheath — sometimes it must be removed by careful dissection. As with all benign tumors, lipomata cause disablement just so far as they interfere with function. A fatty tumor as large as a dinner-plate, when situated between the shoulders, is not troublesome. A fatty tumor the size of a man's thumb, if it protrude into the knee- joint, may cause great pain and result in serious crippling. The "lipoma arborescens" of Midler is xhe common example of the latter TUMORS OF THE CONNECTIVE-TISSUE TYPE 827 form, the joint lipoma, and is often associated with rheumatoid arthritis. Subserous lipomata situated behind the peritoneum may attain enormous size; may occur at almost any age; may seriously interfere with visceral function; and may be mistaken for grave abdominal tumors. Diffuse lipowata are seen most commonly on the back of the neck. Such lipomata spread without a limiting barrier and may cause ugly de- fo unities. The treatment of all forms of Hpomata is excision. Those encapsu- lated growths which are found on the anterior surface of the body may b'e shelled out readily, while lipomata of the hack call for a more painstaking dissection. Deep-seated encapsulated lipomata usually Fig. olS. — Dissection of lipoma of shoulder. may be scooped out without great trouble. Per contra, diffuse lipomata must be removed with the greatest care in order that no portion of the growth remain. This form of fatty tumor recurs unless it be removed thoroughly. A fibroma is a tumor composed of fibrous tissue; and the pure fibroma is not especially common. Mixed fibromata occur often enough, however, such as fibrolipomata, fibromyomata, fibrosarcomata, and the like. We find the pure fibromata in the female generative organs, the intestine, the gums, nerve-sheaths, and skin. Even so, manv of these pure fibromata are mere curios. Certain of the fibromata of the gums and skin have been already described in other chapters. I have mentioned also those fibrous tumors termed desmoids— smaM 828 MIN(JR SURGERY — DISEASES OF STRUCTURE growths springing" from the muscles, tendons, and aponeuroses. Rarely they may attain a c'onsidera))le size. A psammoma is a hard fibrous tumor of the dura mater. Psammomata are fairly common intra- cranial tumors, and though benign, they may destroy the patient through gradually increasing intracranial pressure. A chondroma is a tumor composed of hyaline cartilage. It is usu- ally found connected with the epiphyses of the long bones. Chondro- mata are dense, hard, and immovable when young; but when mature they may be the seat of cystic degeneration. They may become calci- fied or ossified. The treatment of chondromata is not always easy. Obviously, they call for thorough excision, but thorough excision, if it compromise the ^' Fig. 519. — Diffuse lipoma TMassachusetts General Hospital). epiphyses of the long bones of young persons, may result in a permanent shortening of the limb. On the other hand, the chondroma ma}- attain a great size, and may so far involve the integrity of the bone that its removal implies the amputation of the limb. One may see that the removal of chondromata may call for the highest degree of experience and skill, and that each individual case must be treated upon its individ- ual merits. An osteoma is a bone tumor, which we must distinguish from an exostosis and from an odontoma. Exostoses are irregular outgrowths of bone, while osteomata are distinct tumors composed of bone-like tissue; and odontomata are tumors of dental origin and structure. Moreover, osteomata may be regarded as ossifying chondromata. TUMORS OF THE CONNECTIVE-TISSUE TYPE 829 As for exostoses, wo l)()ii-()w from Bland-Sutton a ('la.ssification of three forms: (1) Those ])roduce(l by ossification of tendons; (2) sub- ungual exostoses which grow beneath the toe-nails; (3) exostoses due Fig. 520. — Osteoma of skull (author's case). to calcification of inflammatory exudates, including that condition known as myositis ossificans. Fig. 521. — Osteoma of mandible (redrawn from Bland-Sutton). The treatment of these bony tumors is quite similar to that of cartilage tumors. Thorough removal usually suffices for a cure — rarely we must amputate. Sarcoma.^ — It is hard to see just whj^ the ancients applied the 1 ffop^, flesh; sarcoid, resembling flesh. 830 -MIXOK SLHGKHY — DISEASES OF STRUCTURE term "fleshy tumor" to this growth, for many of its forms resemble grossly certain forms of cancer. At any rate, the term "sarcoma" was loosely used until recent years, and was applied to many varieties of tumor. To-day "sarcoma means a tumor composed of immature mcsoblastic or embryonic tissue in which cells predominate over inter- cellular material."' Or, as Bland-Sutton puts it: ''A sarcoma may be regarded as a malignant tumor-disease of connective tissue." Ac- cordingly, it may arise in any part of the body where connective tissue exists — and connective tissue is omnipresent. Moreover, sarco- mata know no limitation of age. Commonly, hitherto we have tlivided sarcomata into three classes, according to the shape of their cells and theii' disposition: (1) Round- cell; (2) spindle-cell; (3) myeloid. Fig. 522. — Exostosis of the femur produced by ossification of the tendon of the adductor magnus (Bland-Sutton). The reader of this book is familiar, doubtless, with the various appearances of sarcoma; suffice it, therefore, to remind him merely that the round-cell sarcoma is a simple structure consisting of round-cells with extremely little intercellular substance. Round-cell sarcomata have no lymphatics; they are extremely vascular; they grow rapidly; infiltrate easily; recur quickly; and cause numerous metastatic de- posits. It is said that the smaller the cell, the more malignant the tumor. Lymphosarcoma is a variety of the round-cell sarcoma. Its numerous cells are inclosed in a meshwork resembling that of a lymph-node, but the tumor is in no way to be confcnuided with the granulomata involv- ing lymphatic structures. 1 Roswell Park. TUMORS OF THE CONNECTIVE-TISSUE TYPE 831 Spindlc-rell sarcoma presents on microscopic section a different structure from the round-cell sarcoma. The cells have a spindle shape ■0 Fig. 523. — Large round-cell sarcoma of skin (after Karg and Schmorl). and run in all directions. In this tumor, again, the smaller the cell, the more malignant the growth. Alveolar sarcoma is a rare subdivi- Fig. 524. — Round-cell sarcoma (Fowler). sion of this form. The spindle-cells assume an alveolar arrangement suggesting the epithelial cells of carcinoma. We observe, however, 832 MINOR SURGERY — DISEASES OF STRUCTURE in alveolar sarcoma a delicate reticulum between the celLs — an arrange- ment never met with in carcinoma. Myeloid or giant-cell sarcoma resembles structurally the red nuirrow of growing bone and contains many nuiltinuclear cells in a matrix of round- or spindle-cells. These are the tumors of long bones, and con- stitute also the majority of those growths known as epulis. When round-cells, spindle-cells, and giant-cells are found in nearh' equal proportion, the tinnor commonl}- is called a mixed-cell sarcoma. Osteosarcoma, as Roswell Park points out, is more than a sarcoma of bone, for mere sarcoma of bone may spring from the adjacent fibrou::* or the medullary elements. Osteosarcoma is sarcoma of the bone- forming connective tissue, including the osteoblasts and the osteo- /i^^r # ^' r >^ Fig. 525. — Small spindle-cell sarcoma of the skiu \ X 250'i ('after Karg and Schmorl). clasts; in other words, the stroma of bone. Consequently genuine bone develops throughout the tumor, which is essentially a neoplasm. We must distinguish these tumors, clinically as well as histologically, from the medullary sarcomata which develop within the bone, and expand it sometimes to enormous proportions, the bony covering be- coming a mere shell. Chondrosarcoma resembles osteosarcoma. It is a sarcoma springing from the stroma of cartilage-producing tissue. Says Bloodgood^ : " When the giant-cell tumor occurs as a medullary gro'«i:h, it expands the bone (like a bone cyst). It may be as slow of growth as a cyst. The x-ray shadow does not distinguish it positive!}' 1 Joseph C. Bloodgood, Conservative Operations on Bone Tumors, Jour. Amer. Med. Assoc, February 1, 1908. TUMORS OF THE COXNECTIVE-TISSUE TYPE 833 from any other tumor having a bone shell. This tumor has been per- manently cured by simple cureting. Recurrences have followed cureting, but were permanently eradicated by a second operation of cureting, resection, or amputation. . . . One should not attempt cureting unless there is a thick shell of l)one, so that the curet or chisel removes a zone of bone bej'ond the tumor. ... As this tumor is relatively frequent, and as in this country amputation has been the operation of choice, a knowledge of its (the tumor's) characteristic appearances should be acquired by surgeons. . . . This tumor has a character- istic appearance in the fresh state. When first seen at the exploratory incision, it strikes one by its very hemorrhagic, mottled coloring. The .-. "<- ^•-- /c**" ^'e *fe. ■A'>, 5te^ -*^ ® JE? ^ * '^^ ^ ■« *■* '•-•♦^ >^- y / Fig. 526. — Giant-cell sarcoma of upper jaw (X 250) (after Karg and Schmorl). majority of areas are red, with here and there specks or smaller masses of a pinkish white. The tumor is friable and can be broken up into irregular masses. At first sight it resembles hemorrhagic granulation tissue, but it is firmer and less succulent." Says Bloodgood further; "I am of the opinion that the term osteo- sarcoma should be given only to the bone tumor associated with new bone formation. As a matter of fact, this is observed, to any extent, only in the periosteal tumor. This sarcoma of bone, characterized by spicules of new bone foraiation radiating from the shaft between which tumor tissue is present, occurs most commonly on the lower jaw. In my experience none of the cases has given metastasis. Local resection should be the operation. The tumor has a distinct capsule and does 53 834 MINOR SURGERY — DISEASES OF STRUCTURE not infiltrate the surrounding- muscles; it must, however, be removed with the shaft of the bone which it surrounds." Bloodgood makes the following interesting observation on the character of the urine in cases of bone tumors : " In the multiple myeloma of bone, Bence-Jones bodies are present. Clinically, this hopeless disease of medullary tissue ma}^ in a few instances present itself as a single bone lesion. In this stage, even 2:-ray studies of other bones may fail to show any other lesion. If the urine is not examined, the surgeon would proceed to a radical operation on the apparent single bone lesion without any suspicion of its multiple nature. The medul- lary growth of the myeloma in its early stage expands bone and resembles Fig. 527. — Enormous fibrosarcoma (Massacluisetts General Hospital). the giant-cell sarcoma or bone cyst. Later, the bone capsule is de- stroyed. It is important to remember that in some instances the benign bone cyst may be a multiple lesion. The cases thus far recorded have been associated with osteomalacia." Endothelioma is a form of tumor whose true character has been only recently determined. It is made up of those endothelial cells which line the lymph-spaces, and it occurs most often in the skin, especially in the parotid region, in the genital glands, in the bones, the lymph- nodes, and the dura. The growths frequently simulate epithehoma, Endotheliomata grow rapidly, and often are extremely malignant, while metastases occur early. The only hope of a cure is in prompt and most thorough extirpation. TUMORS OF THE CONNECTIVE-TISSUE TVl'E 835 There are suiuliy other t'oiins of sarcoma, not very common. Angiosarcoma is a sarcoma arising from the adventitia of blood- vessels; thus it differs from the endothelioma, which springs from the "^*. ■*<2i-s*' Fig. 528. — Mixed tumor of the parotid gland (Massachusetts General Hospital). lining of the lymph-spaces. Angiosarcoma is astonishingly vascular, and on section is found often to be the seat of numerous hemorrhages Fig. 529. — Sarcoma of humerus, round-cell. Two months' duration (Coley). which take place into its own structure. Often, therefore, it is deeply pigmented. A subvariety of angiosarcoma is the perithdiovia, which grows especially in the bones, the kidneys, and the skin. Perithelioma 836 MINOR SURGERY — DISEASES OF STRUCTURE arises in the perithelia! cells between the capillaries and the peri- vascular lymph-spaces. Both of these forms of sarcoma — angiosarcoma and perithelioma — are extremely malignant and difficult of extiipation. AVe apply the term cylindroma to a tumor of the angiosarcoma type, in which hyaline changes have occurred, so that the cylindric masses of altered cells appear along the course of the vessels. Certain sarcomata take on a deeply pigmented appearance and are known as melanosarcomata. These tumors are not to be con- founded with the pigmented angiosarcomata, though, indeed, they are equally or more malignant. Melanosarcomata appear uniformly and deeply stained, the staining being due to a deposition of blackish pig- ment both in the cells and in the intercellular substances. When removed, these tumors (known commonl}^ as melanomata) almost CUr' tr _ Fig. 530. — Osteosarcoma of the humerus (Massachusetts General Hospital). invariably recur. We must observe that the term mdanoma is confined almost invariably to tumors of the sarcoma type. Epithelial tumors rarely, if ever, become melanotic. In regard to all sarcomata the reader should remember that, although they often seem quite isolated from the adjacent tissues, and even to be surrounded by a sort of capsule, nevertheless careful examination shows the cells to have invaded the surrounding tissiies. There they proliferate rapidly, and detached foci may be found at a considerable distance from the parent tumor. Sarcoma has the power also of pro- ducing metastatic deposits often so small and numerous that the term sarcomatosis is used to describe the condition. The metastases of sar- coma, however, occur later in the course of the disease than do the metastases of carcinoma, so that a local return of sarcoma may take place several times after operation before generalization of the growth occurs. TUMORS OF THE CONNECTIVE-TISSUE TYPE 837 Sarcomatous metastases take place along the course of the blood- vessels rather than of the lymphatics, although in the case of osteo- sarcoma the lymph-nodes may become involved. Early in its career sarcoma often is but slightly malignant. It may long appear to remain stationary, so that when we attack it early we may reasonably expect completely to eradicate the growth in many cases. Myxoma is a term applied to tumors composed of mucous tissue, such as the Whartonian jelly of the umbilical cord. We must dis- tinguish the true myxoma from myxomatous degeneration. We find myxomata as gelatinous polypi in the nose and in the external auditory canal; as sessile tumors hanging from the skin of the perineum and labia; and as neuromyxomata, involving the nerve-trunks. All myxo- mata should be thoroughly extirpated and the wound cauterized, for although these growths are not properly malignant, they tend to recur again and again, giving rise to chronic and long-continued dis- turbances. A myoma is a tumor composed of unstriped muscle-fibers; hence we find these growths, as we should expect, in certain definite locations — in the uterus. Fallopian tubes, the vagina, esophagus, alimentary canal; in the prostate, bladder, and skin. The tumors are encapsulated commonly, and are composed of fusiform muscle-cells with rod-like nuclei. Often they grow as mixed tumors, so that when found in the uterus especially we describe them by the term fibromyoma or myo- fibroma. They are properly non-malig-nant, but accumulating experi- ence teaches that a uterus long the seat of a myoma may eventually develop carcinoma. The complete removal of a myoma cures the disease. Angioma is the term applied to tumors composed of blood-vessels — nevus, cavernous angioma, arterial angioma, etc. I have already described these growths elsewhere in the chapters on Regional Sugery, especially in Chapter XXVII. By the term lymphangioma we mean a tumor composed of lymph- vessels — a tumor resembling in many respects an angioma. There is the lymphatic nevus, a mass of lymphatics found sometimes upon the surface of the body, but most often on the lip and tong-ue. The tongue so affected may become greatly enlarged, and protrude from the mouth. This form of enlarged tongue is called a macroglossia. Cavernous lymphangioma is a condition in which the lymph-vessels become greatly distended and sacculated. Lymph cysts are still more exaggerated forms of lymph-vessel dilata- tion. These cysts are usually encapsulated, and give rise to that peculiar condition I have already described (Chapter XXVII) under the caption Elephantiasis. A word about the treatment of the lesser forms of lymphangioma: formerly they were removed by dissection, by electrolysis, and by injections of boiling water. Recently we have found that the applica- tion of liquid air, or, better, carbon dioxid snow, suffices to cure the ailment, and that the resulting scar is trifling. 838 MINOR SUKGEUY— DISEASES OF STFilCTrHE So much, biiolly, for the connective-tissue group. The neuromata constitute our fifth group, uud with the neuromata I have iihviuly dealt in Chapters XXIV and XXV. We must say a word further of glioma. Tliis is a malignant tumor found generally in the brain, rarely in the spinal cord. It is extremely malignant; springs from the nervous tissue; and appears as a trans- lucent swelling infiltrating the surrounding tissue. It has a thin, gel- atinous consistency, and, microscopically, it resembles neuroglia. It does not form metastases; it is extremely vascular; it proves its malig- nancy by destroying adjacent structures. It may appear in the orbit and the eye; and it is more common in the young than in the old. Fortunately, glioma is one of the rare forms of nervous tissue tumor. Though operations for its relief have been undertaken, they have given no more than temporary relief. We have already discussed neuroma and plcxifor7n neuroma (Chapter XXVII). Malignant neuroma is properly a sarcoma of the nerve structures — a sarcoma usually of the spindle-cell variety. EPITHELIAL TUMORS Epithelial tumors constitute our group six. Like tumors of the con- nective-tissue group, they are benign and malignant, but the most benign epithelial tumors (moles and warts) even may become malignant, -•*???■> i // V Fig. 531.— Cutaneous horn (Massachusetts General Hospital). as recent observers have demonstrated. Papilloma is the common type of a non-malignant epithelial growth, and of papilloma there are several varieties. Warts I have already described in Chapter XXVI. EPITHELIAL TUMORS 839 Of the innocent wart, let us recall this significant fact : when of long standinf;-, and in an individual no longer young, it may develop into a truly malignant epillu^lioma; for the benign wart, which springs up- ward and grows without damage to surrounding structures, later may progress downward, may sink deeply into adjacent tissue, and may become a true cancer. For this reason we should not hesitate radically to remove warts and "moles" of long standing. Villous papilloma grows in the bladder and in the pelvis of the kidney. This tumor springs from the mucosa. It has long, fern- like villi, and disturbs the patient by hemorrhage only or by choking the urinary channels. Villous papilloma may arise from the choroid plexuses of the lateral ventricles of the brain. Villous papillomata, when accessible, should be removed, lest they become malignant. Cutaneous horn (Bland-Sutton). There are intracystic villous growths and there are ovarian papil- lomata. The ovarian papilloma may be maHgnant, for if broken up at the time of operation, the particles seem to attach themselves to the peritoneal surfaces, and there to grow luxuriantly. Cutaneous horns are epithelial growths. Bland-Sutton has a long and interesting chapter on cutaneous horns. He describes sebaceous horns, warty horns, horns growing from cicatrices, and 7iail horns. These are all benign growths and should be thoroughly removed. We have already described in their appropriate chapters various forms of epithelial disease of the thyroid gland {goiter) and of the ovaries, especially that form of glandular cystoma, the multilocular cyst, with numerous cavities filled with fluid, and containing a small number of 840 MINOR SURGERY — DISEASES OF STRUCTURE epithelial cells, while the cyst-wall may contain tubular, gland-like structures reaching into the surrounding connective tissue; and the papillary cystoma, a cyst presenting projecting papillomatous growths into the cyst cavities — growths covered by cylindric epithelium; and we recall that the glandular and papillary types frequently are blended. An adenoma (also Jlbro-adenoma) is a tumor whose type is the normal secreting gland. Now the adenoma differs from the gland in that it is an abnormal outgrowth; and further in that it has not the power of secretion peculiar to the analogous gland which it represents. Adenomata are circumscribed tumors found most commonly in the breast, the parotid, the thyroid, the liver, and the mucous lining of the bowels and uterus. Adenomata may be single or multiple; they may be small or very large; they do not involve the lymphatics or give rise to metastases. They are easily confounded with cancer, into which they may readily degenerate; or the two may coexist. A cancer of the adenomatous type is commonly referred to as an adenocarcinoma. Fig. 5.3.3. — Epithelial odontoma fredra\\n from Bland-Sutton). Fihro-adenoma is a small hard tumor found commonly in the breast of young women, encapsulated, usually superficial, movable, and often multiple. Of recent years it has become the fashion, following the lead of Bland-Sutton, to classify separately tumor diseases of the teeth — odontomata. More properly, perhaps, these timiors should be classed either with the connective-tissue or with epithelial groups. "An odontoma is a tumor composed of dental tissues in varying proportions and different degrees of development, arising from teeth- germs, or teeth still in process of growth" (Bland-Sutton). We must recognize three distinct elements in the developing tooth — the enamel- organ; the papilla, from which the dentin is derived; and the tooth- sac, which furnishes the cementum. Early in its development the various tissues of the tooth are soft and enveloped in a sac which lies buried along the borders of the jaws. Accordingly, we have epithelial odontomata, which have a capsule, and appear usually as a series of cysts containing mucoid fluid, while EPITHELIAL TUMORS 841 the growing portions have a red tint, not unlike sarcoma. Epithelial odontomata are scon most commonly about the twentieth year of life. Follicular odontomata are those tumors which have commonly been called '' dentigerous cysts." Unlike the epithelial odontomata, these growths ai'ise in connection with the prmanent teeth, especially the molars. They may reach a considerable size and cause a marked deformity. The tumor is made up of a wall — the expanded tooth- follicle— and of a cavity containing viscid fluid, as well as some portion of an imperfectly developed tooth. The cyst-wall always contains calcar- eous material. These tumors rarely suppurate. Fibrous odontomata also arise in connection with developing teeth. They are formed of dense connective tissue, and appear as tumors with a firm outer wall and a loose inner texture — blending at the root of the tooth with the dental papilla. The developing tooth thus becomes in- closed within the tumor capsule be- fore it protrudes from the gum. These tumors are more common in cattle than in man. The growths often are multiple. A cementoma is a fibrous jaw tumor whose capsule has calcified. It springs from a developing tooth which becomes embedded in a mass of dental cement. These tumors are most common in horses. Compound follicular odontomata contain a mimber of masses of cementum resembling small teeth, or they may amount even to well- Fig. 534. — Follicular odontoma (Bland-Sutton). Fig. 535. — Composite odontoma (Bland-Sutton). developed but misshapen teeth, composed of all three dental elements. In these compound follicular odontomata many teeth are found. Human beings are frequently subject to this disease. Radicular odontomata spring from the dentin and cementum after the crown of the tooth has been formed, and while the roots are still developing. These growths are more common in animals than in man. 842 MINOR SURGERY — DISEASES OF STRUCTURE Composite odontomata are hard tumors composed of enamel, dentin, and cementum. Thus they contain all the elements of the tooth-germ, but they bear little resemblance to normal teeth. They are found in man only. These tumors of the jaws seem to have attracted the attention of the older rather than of the more recent writers, yet present experience shows us that they are quite common, especially in young persons. An extremely significant fact is that frcciuently odontomata are mis- taken for sarcomata, so that we learn this lesson: all tumors of the jaws which are not obviously malignant should be explored carefully for the detection of odontomata before a resection of the jaw is done. The odontomata can always be satisfactorily treated by a complete excision, which should leave little deformity, and should result in the restoration of a normal and useful jaw. CANCER Cancer is a term of wide-reaching significance. In ancient times writers seem to have used the word to describe all manner of malignant growths; and in our own day, clinical writers in general terms have applied the word " cancer" to tumors structurally as different as sarcoma and malignant epithelioma. Commonly, however, we mean by cancer carcinoma,^ "a tumor composed chiefly of epithelial cells, differing more or less in their type and arrangement from the usual epithelial structures, and having a tendency to an unlimited growth. These cells grow into the surrounding connective tissue, which is thereby stimulated to increased development. Carcinoma is composed, there- fore, of two distinct structures — epithelial cells and the vascular stroma" (Warren) . Cancer is a disease of paramount importance because, when untreated, it is almost invariably fatal, though recent studies in immunity are lead- ing us to believe that the occasional spontaneous cure of cancer is credible. Cancer is marked by its insidious onset; by its painlessness in its early stages; l)y its progressive and irresistible destructiveness; by its mysterious dissemination (see the Theory of Handley in Chapter XIX); by its involvement of the lymph-nodes; by its metastases in remote parts; by the hopelessness, misery, and pain it produces when fully developed; and by the extreme difficulty of its extirpation. I shall have occasion shortly to point out our present hope for its cure. Carcinoma and epithelioma are terms which should be obvious enough, yet modem writers still employ the words in a somewhat confusing sense. For example, Roswell Park says of carcinoma that it is a tumor springing from preexisting gland tissue; and of epithelioma, that it is common especially where there is transition from one kind of epithelium to another ; while Bland-Sutton - does not use the terai epithelioma at all. 1 Greek, KapKivoc, a crab, a term, according to Uelsus, applied to malignant growths on account of a crab-like appearance, due to the great enlargement of super- ficial vessels centering about the tumor. 2 Keen's-Surgerj', vol. i. CANCER 843 I prefer to use the Avonl < piiluiiotiKi iind carcinoma as interchanguble. By epithelioma Ave uiulerstiiud a nuilignant tumor comi3osed chiefly of epithehal cells, and that definition applies also to carcinoma, a disease \vhich is not limited by any means to gland tissues. This confusion of terms, as Warren reminds us, is due to the fact that in past times the word epithelium was used to describe cancers consisting of pavement epithelium. Carcinoma (or epithelioma), accordingly, has various subdivisions, all of them differing from the non-malignant papilloma in that they are not limited by a basement membrane, but pass beyond it into the Fio- 536 —Epithelial pearl formation in squamous epithelioma (middle power) ^' ■ (Park). underlying connective tissue. Wherever epithelial structures exist, there carcinomata may develop, and our opportunities for observing the appearances of cancer depend upon the cancer site. A cancer^ of the tongue, the lip, or the penis is instantly obvious, and may be studied from the outset. Cancer of the stomach, of the intestine, or of the uterus is long latent, and usually comes into the field of observation when the disease is well advanced only. Incidentally we see that for these reasons the early observed superficial cancers frequently are cured, while internal cancers, observed late, are cured far more rarely. ^^ Superficial cancer — squamous-cell cancer— apipeavs usually as a 844 MINOR SURGERY — DISEASES OF STRUCTURE wart-like growth or nodule, which quickly becomes an ulcer with elevated edges, the ulceration being due to the necrosis of the cells farthest from the periphery; or, again, the disease may start as an ulcerated fissure. — ulceration and infiltration keeping pace, — in which case there is a sharply defined ulcer with undermined edges. A third variety of squamous-cell cancer often seen upon the lips comprises a projecting mass, with a more or less homy surface. In nearly all of these, however, characteristic cell-nests, with their onion-like arrange- ment of cells, willj)e found" (Roswell Park). Such is the superficial epithelioma. Fig. 537. — Metastasis of squamous epithelioma in a lymph-node. (middle power) (Park). Pearl formation All observers dwell upon the invariable lymph-node involvements which accompany cancer. The lymph-nodes in cancer are invaded early. Sometimes our first intimation of malignant disease comes from finding the enlarging lymph-nodes; later we may discover the original cancer focus. I have referred more than once to Handley's ingenious theory of cancer dissemination, and have described it in Chapter XIX. Moreover, our studies of cancer in the chapters on Regional Surge r}^ render needless further and special description of cancer here. I refer the reader e.specially to Chapters XX and XXI for descriptions of rodent ulcer, that most shocking, chronic, and dis- figuring of diseases; and of cancer of the tongue, lip, and jaws. The varieties of cancer referred to in the preceding paragraphs are CAXCER 845 commonly known as sqitamous-cell cancer — cancer which makes its appearance on any surface covered with stratified epithehum. It may be worth while to recapitulate some of the important locations where such cancers are found: on the lips, tongue, cheek, vulva, anus, scrotum, gians penis, conjunctiva, pinna, urethra, about scars and chronic ulcers, and on the neck of the uteiiis. Of late years we have heard much of precancerous conditions, and Bland-Sutton and other writers have dealt" especially upon leukoplakia of the tongue and buccal mucosa as a condition precedent to cancer. Doubtless such precancerous conditions are extremely common, if only surgeons might observe them and recognize their significance. Gland cancer is important ec[ually with cancer of the squamous-cell variety. Gland cancer resembles the gland tissue from which it springs, except that the stiiictural similarity is incomplete. The epithelial cells collect in irregular clusters, fill the acini, obstiiict the ducts, and invade the surrounding tissues. These cancers may arise from any secreting gland; they spread rapidly. Distant metastases appear early, and it is an extremely interesting characteristic of these metastases that they reproduce almost perfectly the type of primary tumor whence they spring. For this reason the study of such a metastatic growth frequently gives us definite information as to its origin. The classic types of gland cancer are found in the breast, and the intricate and numerous manifestations of breast cancer have already been described in detail in Chapter XIX. I need add nothing here to what I there stated beyond naming other organs subject to this disease — the salivary glands, liver, kidney, ovary, and testicle. More- over, the squamous and gland types of cancer may overlap and co- exist . For a brief description of mcdignant chorio-epithelioma, or the deciduoma mcdignum, and of suprarencd epithelioma — hypernephroma, 1 refer to Chapters X and XIII. The following tables, taken from Roswell Park's Modern Surger}', mav assist the student in his studv of tumor diagnosis : TABLE I.— DIFFERENTIATION BET'U'EEN BENIGN AND MALIGNANT GRO^yTHS. Bexigx Gro"r-ths. Common at all ages. Tjsually slow in gro-^^th. No evidences of infiltration or dissemin- ation. Are often encapsulated, nearly always circumscribed. Rarely adherent unless inflamed. Rarely ulcerate. Overlj-ing tissue not retracted. No lymphatic involvement when not in- flamed. No leukocj'tosis. EUmination of urea imaffected. Malignant Growths Rare in early life. L^sually rapid in growth. Infiltration in all cases, dissemination in many. Never encapsulated, seldom circimi- scribed. Always adherent. Often ulcerated — nearly always when surface is involved. Overlying tissue nearly always retracted. Lymphatic involvement an almost con- stant feature. Leukocj"tosis often marked. Deficient elimination of urea (?). 846 MINOR SURGERY — DISEASES OF STRUCTURE TABLE II.— DIAGNOSIS BETWEEN SARCOMA AND CARCINOMA. Sahcoma. Occurs at any age. Dissciniuutcs by tlie bkioil-vcssels (^veins). Arises from inesoblastic structures. Distant metastases arc more common. Contains blood-channels rather than complete blood-vessels. Less prone to ulceration. Involvement of adjacent lympliatics not common. Secontlary changes and degenerations are more common. Sugar present in the blood . Carcinoma. Rare before thirtieth year of life. Disseminations by the lymphatics. Arises from glandular (cijithelial) tis- sues. Less so. Contains vessels of normal type. More so. Almost invariably atljacent lymphatics are involved. Degenerations not common; other sec- ondary changes rare. Peptone present in the blood . TABLE III.— DIAGNOSIS BETWEEN EPITHELIOMA AND TUBERCULO- SIS (LUPUS). Epithelioma. Preceded usually by continued irritation or warty growths. Diathesis plays no known part. Rarely multiple. Area of thickening ahead of ulceration. Ulceration advancing from a central focus. Border usually raised and everted, regu- lar in outline. Often assumes fungoid type. Base may be deeply excavated. L^sually painful. Bleeds easily. Never tends to cicatrize. Most rare in the young. Discharge is verj' offensive. Lymphatic in\olvement nearly always. Tuberculosis (Lupus). Irritation plays no figure. Preceded usually by nodules. Diathesis evident. Coincident evi- dences of tuberculous disease else- where. Often multiple. Extension of ulceration not preceded by thickening. Various foci, which may coalesce. Border abrupt, eaten, irregular, thick- ened, firm, often inverted, irregular in outline. Never fungoid. Base nearly level with surface. Seldom painful. Seldom bleeds. As marginal ulceration proceeds there is often cicatrization at center. Common in the young. Discharge rarely offensive. Rarely. After all is said, what shall we tell the student and the general prac- titioner regarding the surgeon's attitude toward the cancer problem, and the question of its cure? This is no place in which to discuss the great question of the causation of cancer, as I have already stated. Doubtless should investigation prove to us that cancer is of parasitic origin, the inevitable next step of finding its antidote would follow. To-day, however, we are faced with the problem of present treatment, and surgeons are finding that the careful and extensive modem opera- tions are lowering cancer mortality. I have already said that super- ficial cancer may and should be attacked early. As Crile remarks in his illuminating paper,* we should not wait for the disease to develop * Oration in surgerj'' before the American ]\Iedical Association, published in the Jour. Amer. Med. Assoc, June 6, 1908, p. 1883; also. Jour. Med. Research, 1908, xlvii, 385. CANCER 847 itself in order to establish a diagnosis; we should remove the disease as soon as it is seen, and then establish our diagnosis. In several fore- going chapters of this book I have already described the various and elaborate methods of operation now in vogue. Our endeavor must be, therefore, to arrive at an early diagnosis. How shall we do this in the case of those cancers which are hidden from view? Says Crile : " I have often thought that, pending a more general enlightenment, it would be a great boon to mankind if the words ' glan- dular enlargement and cachexia,' as denoting symptoms of cancer, were stricken from every text-book of medicine. These are terminal symp- toms, and indicate that the surgical opportunit}' is forever lost. Were the result not so tragic, such professional simple-mindedness would be ludicrous." Through his studies in hemolysis, Crile has arrived at an extremely interesting and probably valuable hypothesis which he is applying' to the diagnosis of early cancer. To quote: "The blood-serum of a cancer patient may hemolyze normal corpuscles, but normal blood- serum usually does not hemolyze the red corpuscles of a cancer patient. In some patients— thus far only those with inoperable cancer— there was reverse hemolysis. The cancer corpuscles were hemolyzed by normal serum. In some cases there was no reaction. If this reaction is to be of diagnostic value, then it must occur in cancer cases only or m diseases not readily confused with cancer." In other words, we have in the hemolysis blood-test a promising method for the determination of early internal cancer; and Crile's statistics, already considerable, show this test to be fairly reliable. Crile makes this further intensely interesting statement: '^The work of Gaylord and Clowes, Beebe and Ewing, Ehrlich, Loeb, and others, demonstrating a not infrequent immunity against cancer, was utilized by Beebe and myself in an attempt to cure transplanted sarcoma in dogs by maximum bleeding of the 'tumor dog' and heavy over- transfusion from an immune dog. By this method we have cured of sarcoma nine out of eleven dogs, some of which were cachectic and had metastases. The cured animals in turn became immune and were successfullv emploved for curing and immunizing other dogs. . _ . . Arguing from this work and from the fact that among the lower anmials certain^'ones are naturally immune, we have transfused normal blood into six human subjects having sarcoma, their tumors havmg been removed previously to transfusion. Sixteen months have now elapsed since the first case was so treated (without recurrence) . . . . _ Should these patients be cured (after three or more years) and become nnmune, it is likelv that they may be available for curing others, so that eventually a group of immunes may be established." Crile goes on to say, prop- erlv and guardedly, that ''the whole matter of immunizmg agamst sarcoma is at this time wholly experimental, and my statements are presented with that understanding." Besides the knife, various measures have been and are to-day emploved for the cure of malignant disease. The a--ray and radium have an apparent curative effect in certain superficial cancers. In 848 MINOR SURGERY — DISEASES OF STRUCTURE doubtful cases after operation on deep-seated tumors the skin-flaps may be retracted and the x-rays applied daily and directly to the depths of the wound. Coley's well-known treatment with the mixed toxins of erysipelas and the Bacillus prodigiosus has had promise, and the method has still a vogue. The best results have been obtained by Coley himself. Numerous other measures have been advocated and are still advo- cated, such as ultraviolet rays, pyoktannin, formalin, etc.^ One of the most interesting of these measures is that of Beatson, of Glasgow, who suggests the benefit of the removal of the ovaries in hopeless cases of mammary cancer. He has reported instances of apparent cure. The so-called ''trypsin treatment" of malignant tumors was promulgated by Beard, of Edinburgh, and still finds its advocates, who assert that although the record of cases is far from perfect, still the reasoning on which the treatment is founded should prove correct when worked out in more detail. In brief and unsatisfactory detail such is the problem of the treat- ment of malignant tumors as we see it to-day. Save for the campaign against tuberculosis, no campaign in all medicine is being more actively pushed than this cancer campaign; and we have strong reason to believe that within the years immediately coming we shall arrive at a clear understanding of the nature of malignant disease, and shall obtain a rational, safe, and sound remedy. 1 Skene Keith and George E. Keith report great relief from pain and marked improvement in the general condition of the patients from the hypodermic use of a compound of iron, sodium, and iodin. To quote: " This strong standard injection consists of a solution of iodipin in oil, arseniate of iron, cacodylate of iron, and cin- namate of sodium.. The iodipin is a 25 per cent, solution in oil. The arseniate of iron contains | grain of iron and j^ grain of arsenious anhydrid in 1 cc. The caco- dylate of iron contains 3 grains of iron in 1 cc. The cinnamate of sodium is a satur- ated solution containing li grains to the cubic centimeter. . . . The average proportions of the emulsion which we have used most are as follows: 1 dram of the iodipin and 20 minims each of the other three. . . . The dose varies also. Some patients appear to do well with 5 cc. of the emulsion given everj" second day or even every day, while it seems to be advisable with others not to give more than 2 or 3 cc." — Cancer, Relief of Pain and Possible Cure, p. 33. Almost equally useful apparently is the treatment advocated for cases of in- operable cancer by G. W. Gay, of Boston, a treatment I have used myself vritb .satis- faction: Give 5 drops of the compound solution of iodin three times a day and in- crease the dose rapidly until, by the end of a month, the patient is receiving 60 to 100 drops in the twenty-four hours. Frequently, by the use of this dnig, pain is allayed, the rapidity of the tumor's growth seems to be checked, and life is prolonged. It may be necessary to supplement the iodin by small doses of the tincture of opiimi given by rectum and repeated at short inter\'als — 3 or 4 drops every three hours, the surgeon being careful not to .saturate the patient with the drug. CHAPTER XXIX FRACTURES AND DISLOCATIONS Fractures A FRACTURED bone is a broken bone. I know of no phrase or com- bination of terms that sums it more accurately. In spite of the a:-ray, the treatment of fractures does not form a popular division of surgical practice. . Most surgeons would shun fractures if the}' could. Fractures comprise a department of surgery distinct and unique. Moreover, in a book of this character, it is impossible adequately to deal with the great subject of fractures. For proper details the surgeon should consult the well-knoMTi books of Hamilton, Stimson, or Scudder. It will be useful, however, for the student to gain some general idea of fractures and their treatment from such a brief essay as I can address to him here. In the first place, let us consider some general topics in comiection with fractures, and then briefly review special fractures and their treat- ment . Commonl}-, fractures are described in various terms. To quote Eisendrath,^ fractures are classified: I. i^ccording to their degree. II. According to the direction of the line of fracture. III. According to their location. IV. According to their etiology. V. According to their relation to the overh'ing skin. VI. According to the number of fragments. VII. According to whether or not they are complicated. This classification is good, and certainly expresses recognized con- ditions. I. Fractures are complete or incomplete and we use also the terms green-stick and subperiosteal. II. Fractures are transverse or oblique. III. Fractures are epiphyseal when the epiphyses, commonly in young persons, are separatecl; while the fracture remote from the epiphysis is spoken of as a fracture of the shaft. We speak of joint fractures also, meaning fractures involving the joints adjacent to the break. TV. "We describe a fracture as direct and indirect also — referring to the manner in which it was received. A direct fracture is one caused by a crushing force applied to the seat of fracture. An indirect frac- ture is due to muscular violence, straining the bone until it breaks. 1 Daniel N. Eisendrath, Fractures, Keen's Surgerj', vol. ii. 54 849 850 MINOR SURGEHY — DISEASES OF STUUCTLRE V. Perhaps the most important division of this classification is that which separates fractures into sinij)lc fractures and conijxmnd fractures. A simple fracture is one in which there is no communication between the broken bone and the outer air. A compound fracture is one in which there is a wound leading to the fracture through the skin and soft parts. Of recent years many writers, following the phrasing of Scudder, have substituted the terms dosed and open fractures for simple and compound fractures. VI. In case the bone is splintered into three or more fragments, we use the term comminuted fracture. The term multiple implies a some- 4. 5. 6. Fig. 538. — Various forms of lines of fracture: 1, Complete transverse; 2, longitudinal; 3, oblique; 4, spiral; 5, incomplete or green-stick; 6, subperiosteal (Eisendratli). what different condition, and signifies that one or more bones are broken at several points. VII. When a fracture is but a part of the injury received, that is, when soft parts and organs as well as bones are damaged, we employ the term complicated fracture, though this is, perhaps, a fanciful and needless classification. GENERAL CONSIDERATIONS Certain considerations recently have become prominent in the discus- sion of all fractures, considerations which are more interesting perhaps to the general surgeon than are questions of the diagnosis and treat- ment of the average fracture. We are discussing and questioning the inevitable value of the rc-ray. W^e are considering the more frequent treatment of fractures by opening down upon and wiring or othenvise fixing the fragments beneath the skin. We are devising methods of treating the old deformities which sometimes result from faulty union of fractures; while one of the most important of recent discussions deals with the treatment of delayed union and especially of the non- union of fractures. GENERAL CONSIDERATIONS 851 After the introduction into practice of iic-ray examinations, some fifteen yc;irs ngo, it was felt at first that at last we had secured a positive and unfailing niethotl of reaching the exact diagnosis of a given fracture. X-ray pictures were assumed to be infallible, not only as indicating the position of the bone fragments, but as demonstrating surely the func- tional results of treatment — that is to say, the value of the limb to the patient after the bone had healed. Such conceptions of the use of the x-YSiy have been greatly modified. Its indiscriminate employment has done harm as well as good. It has led to the superficial and care- less palpation of fractures; it has induced young and inexperienced practitioners to rely entirely upon the a:-ray picture, and it has imposed upon juries the notion that bones, the fragments of which are not approximated absolutely and accurately, must be of faulty function after union, and must show careless treatment. As a matter of fact, it is rare that closed fractures can be absolutely approximated, while it is the experience of surgeons for ages that imperfect apposition commonly may coexist with almost perfect function. Cotton ^ has very properly stated that the most important use of the a:-ray is to determine the position of the bone fragments after the sur- geon has reduced the fractvire. That writer would employ the a- -ray when convenient, as an aid in the determination of the exact natnre of the fracture, bearing in mind always that other and common methods of investigation should not be neglected; but after the fracture has been reduced and has been held in its new position for a time sufficient to allow the healing process to begin, he would then secure another x-ray picture. By the aid of this latter picture the surgeon is able to deter- mine whether or not his treatment is effective, and, if necessary, he can then remedy malposition. After union is complete and the limb is again in use, the rc-ray is of no value whatever, provided function is satisfactory. For, as I have said, the perfectly functionating limb may be supported by a bone which shows a marked deviation from the normal. The open treatment of fractures is too seldom used. In general terms it is true that a closed fracture, well approximated, promises a good result without further molestation; but many fractures, after reduction has been attempted, show continued deformity, marked failure of apposition, and a tendency to delayed union. Cotton ques- tions the frequency of the interposition of soft parts as a cause of mal- position and delayed union. My experience is somewhat different. I have seen several cases of fractured fibula and ulna in which interposed tendons obviously prevented a proper apposition of the bone fragments. In such cases I advise the surgeon to cut down upon the damaged bone, without hesitation, to push aside the soft parts, and to wire the frag- ments. Again, in the case of a comminuted fracture involving a joint — especially the elbow-joint — frequently it occurs that with the patient etherized, proper motion of the joint is found to be impossible. The joint 1 F. J. Cotton, Notes on Fractures and Their Treatment, Boston Med. and Surg. Jour., July 27, 1905. 852 MINOR SURGERY — DISEASES OF STRTCTrRE locks. It can neither be extended nor flexed normally. In such a case the surgeon should exphiin the situation to the patient; .shoukl make clear to him the inipossibiHty of satisfactory function without an operation, and the possible dangers of an operation, and should insist that the patient himself, or his friends, if necessary, elect the course of procedure. In connection with this matter of simple and compound, or closed and open fractures, let me remind the student that until the antiseptic era the dangers of the open fracture were incomparably greater than the dangers of the closed fracture. Open fractures were nearly always complicated by suppuration, frequently by bone necrosis, often by extensive infections, and commonly by pyemia and death. It was a realization of this shocking situation which led Lister to his studies in antisepsis. We still insist upon the distinction between compound and simple fractures, although the dangers of the former have been nearly eliminated, but danger does still exist, especially when the joints are involved, so that one may not rashly and unadvisedly transform a simple into a compound fracture. Nevertheless, the dangers are now slight. In such cases of joint injuries as I have described- — simple comminuted fractures involving the joints, with the prospect of a stiff joint should no operation be done — one finds one's self confronted with a choice of evils. Good practice in these days recognizes and approves cutting dow^n upon such injuries and removing or fixing properly the bone fragments. Old deformities resulting from the malunion of fractures present to the conscientious surgeon some of the most serious and difficult questions which he can encounter. The questions involved are those of the propriety of former treatment; the possible incompetence of the surgeon who originally reduced the fracture; the possibility of a law suit against that surgeon, and one's own proper action in the premises; with the uncertainty as to whether or not a present late operation will materially improve the unfortunate condition of the patient. These are questions which cannot be answered positively and in general terms. I advise the young practitioner, especialh', to avoid involving himself without consultation in one of these cases. If two competent surgeons agree that a secondary operation will probably improve the patient's condition, then and then only should the attending surgeon undertake the operation. We are finding that a cutting operation directed immediately at the deformity is often of less value than an osteoclasis somewhat remo^^ed from the seat of damage. It may be well, for example, to do osteoclasis for ''gun-stock elbow," or supra- malleolar osteoclasis for a twisted ankle, at the classic point above the joint, entirely irrespective of the seat of the old damage. Delayed union must not be mistaken for non-uynon. Delaj'ed union is common, especially in persons of advanced years, of tuberculous or syphilitic taint, or in poor general health. Such patients should re- ceive painstaking general care with perfect hj'gienic surroundings, tonics, and proper food; while the underlying systemic derangement GENERAL COXSlDERATIOXFi 853 should be treated. It is not uncommon to find union of the long bones, for example, the humerus, the femur, and the bones of the forearm — it is not uncommon to find their union delayed for two, four, or six months. In these cases our duty is faithfully and continuousl}- to inmiobilize the damaged limb. I have seen union take place after twelve months of non-union. In certain rare cases, however, non-union persists, and it is often impossible to determine why it persists. The patient seems to lack proper bone-forming activities, whatever that may mean. The ends of the fragments may atrophj' and an actual false joint — pseudarthrosis ^may develop. I have at this moment among m}- patients an active, sound, and vigorous woman of thirty-five, apparently in perfect health, who has carried for four years an ununited fracture of the ulna, and that in spite of numerous operations for its repair. Happily these cases are extremely rare, though the}' furnish a great amount of discussion in our fracture literature. The treatment of non-union has come to follow a certain fairly regidar routine : (1) Immobilization persisted in for at least six months; (2) irritation of the ends of the bone fragments by friction against each other, with the patient anesthetized; (3) incision down upon, and wiring ^ of the fragments. Each operation should be followed b}' a further, long-continued immobilization. Recentty certain investigations in metabolism, in immunity, and in the processes of wound healing have seemed to lead to a hope of benefit from novel measures. A considerable number of cases of non-union appear to have been cured by the emploj-ment of Bier's passive h}-- peremia; while a still more interesting method is the surrounding of the bone-ends with an aseptic blood-clot, purposeh^ introduced into the tissues, after which the wound is allowed to heal per jprimam. At this stage of our discussion we need not consider special forms of treatment for fractures in general, but it is interesting to reflect that from time to time in the past strange and radical changes in treatment have been undertaken, have been abandoned, and have been revived. As I have said in Chapter XXVI, the beginner would do well to read with care the illuminating essays of Sampson Gamgee on the treatment of fractures, published more than twenty-five years ago. That dis- cursive but delightful writer makes clear the vital importance of rest and immobilization for damaged bones and joints. For generations surgery has recognized the importance of this principle; but surgery has for generations also endeavored in some fashion to accelerate union even while maintaining rest and immobilization. Massage of recent fractures is an ancient practice, long in disuse among modern surgeons, until within recent years. In the chapter on Minor Surgery I have already written at some leng-th on this topic. Surgeons misapprehend often the limits and possibilities of massage ^ This word " wiring" is used as a general term to indicate some form of fixing, whether by silver wire, by nails, by screws, or by one of the numerous forms of plates or clamps which have been devised. 854 MINOR SURGERY — DISEASES OF STRUCTURE for broken bones. There is the too frequent custom of postponing masaii;e until after the splints have ])een removed permanently, and the patient has begun voluntarily to move the limb. Massage at this time is of some value, but its greatest value is found in following the so-called French custom of employing massage daily from the time of the injury. I employ this method with great satisfaction. Massage stimulates the circulation, especially in the lymphatic vessels, and brings fresh blood to the part, in which the massage induces a condition of active hyper- emia. One sees, therefore, that in a sense one of the principles of the Bier treatment is thus attained — indeed, Willy Meyer and other surgeons in this country who have employed faithfully the Bier method, find that it is of distinct value in the routine treatment of fractures. In the case of simple fractures my routine method is to remove the bandages on the third day or as soon as excessive swelling has subsided ; and then, with the limb firmly supported by strapping upon splints, carefully and thoroughly to apply the massage. If convenient and possible, such massage is renewed daily, or every second day, throughout the patient's convalescence. Not only is union accelerated by these measures, but the muscular tone and the circulation are so well sustained that almost as soon as the splints are finally removed the patient finds himself able in fair measure to make use of the affected limb. Let us now take up a consideration of simple and of compound fractures. SIMPLE FRACTURES While we understand by this term a fracture which does not com- municate with the outer air, we must realize that there are varieties of simple fractures. There are traumatic fractures — fractures due to violence. There are pathologic fractures — fractures due to the breaking of a bone weakened by disease (osteomyelitis, tuberculosis, syphilis, sarcoma, carcinoma, rickets, the atrophy of old age, and other similar lesions) . Simple fractures may consist oi fissures only in the bone; of sub- periosteal fractures, in which case the periosteum is not broken, the fragments are not displaced, and the ordinary signs of fracture are not apparent. Frequently this condition has been mistaken for a sprain. There are green-stick fractures, in which case one side only of a long bone is splintered. There are fractures known as spiral fractures, oblique fractures, V-fractures, T-fi"i^Ptures, Y-fractures — the meanings of all of which terms are sufficiently obvious, and they are employed to indicate merely the shapes into which the bones are splintered. The following table, copied from Eisendrath's excellent article — a table for which he acknowledges his indebtedness to Scannell, of the Boston City Hospital — is an interesting statement of the frequency of various simple fractures.^ 1 Simple fractures entered at Boston City Hospital between 1864 and 1905. SIMPLE FRACTURES 855 Simple Fractures. Cases. Per cent. 1. Radius 4657 (13.45) 2. Humerus 3517 (10.16) 3. Ribs 3196 ( 9.23) 4. Femur 2898 ( 8.37) 5. Clavicle 2756 ( 7.96) 6. Fibula 2344 ( 6.77) 7. Metacarpus 1285 ( 3.71) 8. Tibia 1259 ( 3.63) 9. Skull 992 ( 2.86) 10. Tarsus 947 ( 2.73) 11. Phalanges (upper extremity) 798 ( 2.30) 12. Inferior maxilla 692 ( 1.99) 13. Patella 660 ( 1.90) 14. Ulna 630 ( 1.82) 15. Facial bones 538 ( 1 .55) 16. Carpus 495 ( 1.43) 17. Vertebra; 331 ( 0.95) 18. Scapula 256 ( 0.73) 19. Pelvis 208 ( 0.60) 20. Metatarsus 168 ( 0.48) 21. Phalanges (lower extremity) 78 ( 0.22) 22. Superior maxilla 70 ( 0.20) 23. Sternum 40 ( 0.11) 24. Coccyx 20 ( 0.05) 25. Hyoid 1 (0.002) Both bones of the leg 3902 (11.20) Both bones of the arm 1875 ( 5.10) The symptoms and the diagnosis of simple fractures fall naturally into a common paragraph. We hear much of the history of the accident, its general effect upon the patient, and of the age of the patient. These are more or less interesting topics, but in fact they have but the most indirect bearing upon the diagnosis. The symptoms even of the patient are of far less consequence than are the objective signs which the surgeon observes. For example, in describing a fracture a writer will tell you that the patient fell 25 feet, that he landed upon his knee, that he experienced great shock, that he is seventy-five years of age, that he was unable to rise, that his leg is paralyzed, and that there is a bunch on the outer side of his thigh. This is all very well and might lead the reader to the conclusion that the patient is suffering from a fracture of the shaft of the femur; whereas he may have a fracture at the base of the skull, or a rupture of the kidney, which will account for all his symptoms, while the swelling on the outer side of the thigh is a mere hematoma. No; the tmly important, characteristic, and final evidence is to be found upon an examination only of the patient's body by the surgeon himself. There are certain classic, well-recognized, and positive signs of frac- ture: deformity, loss of voluntary motion, abnormal mobility, and crepitus or grating, while the evidence of the x-ray confirms the diag- nosis. Such is the positive and final evidence for which we look. The other facts in the history are more or less interesting, and may have their bearing upon the treatment of the case, but they are not of first importance. I ask the reader to refer again to Chapter XXVI for a descrip- tion of a proper method of handling and examining cases of sus- 856 MINOR SURGERY — DISEASES OF .STUICTLUE pccted fracture. Moreover, as Scuclder states in the first edition of his admirable book on the Treatment of Fractures, "The general emi^loyment of anesthesia in the examination of the initial treatment of fractures, especially of those near or involving joints, has made diag-nosis more accurate and treatment more intelligent. . . . This great certainty in diagnosis has suggested more direct and simpler methods of treatment. . . . The attention of the student is diverted from theories and apparatus to the actual conditions that exist in the fractured bone, and he is encouraged to determine for himself how to meet the conditions found in each individual case of fracture." The patient's interest in his own case is a factor in the situation which will often puzzle the beginner or the inexperienced practitioner. The patient wishes to know how^ perfect will be his use of the damaged limb, and how long he is to be laid up. His interest in the case goes no further than this, unless, as frequently happens, he is contemplating a suit for damages. It is the meeting of these questions so difficult of accurate answer, and the annoyance, with the possible reflection on his own skill, associated with a pending legal suit — it is these considera- tions which have rendered the subject of fractures a grievance and an offense to many a surgeon. The clinical course of an average simple fracture of one of the long bones presents certain characteristics. The limb in the neighbor- hood of the fracture is swollen and tense from extravasated blood and lymph. The parts become pigmented, the limb aches and is extremely painful on being moved, or from involuntary muscular twitching, if the parts are not kept at rest by splints and bandages. During the first week there is commonly a slight rise of temperature (the so-called aseptic fever). If the limb is severely crushed, particles of fat may escape into the circulation, may cause fat embolism in various organs, and may be excreted in the urine. If all goes well, however, and the injury be promptly treated, the swelling subsides gradually, and the pain diminishes and disappears, so that, in the course of a week, the patient rests comfortably, and is conscious only of a disabled and useless limb. In the course of a few days the reparative changes about the seat of the fracture become apparent. Gradually, a soft tumor or collection of exudate of var3'Ing size develops. This is known clinically as the " callus." At first soft, it gradually becomes harder, and in the course of weeks smaller. It constitutes nature's plastic mold or splint, which binds together the damaged fragments. For some wrecks also one can ascertain the progress of the convalescence by examining this callus. While it is soft, the bone fragments move easily within it. As it becomes hard and ossified the union of the bones becomes firmer, so that, in the course of time, a solid union wdthin the callus is assured. The repair of carti- lage as well as of bone follows this course. The time required for the repair of a simple fracture is usually about sixty days. I find it stated in the Cieneral Surgery of Lexer and Bevan that two weeks are rec^uired for the repair of fractures of the SIMPLE FRACTURES 857 phalanges, three weeks for those of the metatarsal bones and the ribs, four weeks for those of the clavicle, five weeks for those of the bones of the forearm, six weeks for those of the humerus and fibula, seven weeks for those of the neck of the humeiiis and the tibia, eight weeks for those of both bones of the leg, ten weeks for those of the shaft of the femur, and twelve weeks for those of the neck of the femur; while consolidation occurs much more rapidly in children and is complete in most of their bones in from two to three weeks. The treatment of simple fractures follows naturalh' enough upon the diagnosis. A great mass of nebulous talk and writing has been indulged in regarding the treatment of fractures. There are, in fact, two vital principles involved. If these principles are observed, all should go well. The fragments of bone must be brought into reasonable apposition and held there. The patient must be made comfortable. Simple as are these two principles, one is astonished constant^ at finding them neglected. Ordinarily, it is not difficult to bring frag- ments into apposition. As a general thing, the patient must be anesthe- tized,— with gas, ether, or chloroform, — when promptly the tense muscles relax and the fragments can easily be brought together. If there is still difficulty in making the approximation, the surgeon may do tenot- omy— especially of the tendon of Achilles — or, if comminuted fragments interfere with each other or protrude into a joint, he may cut down upon and straighten out the tangle. We use the term reduction to indicate the process of bringing the fragments into apposition. The popular word "set" has little meaning. It is far more difficult to fix and immobilize the reduced fragments than it is to reduce them, for with returning consciousness, after anesthesia, the patient involun- tarily contracts his muscles, and muscular contraction tends to throw the fragments out of place. The surgeon must, therefore, apply splints which shall hold the fragments and shall counteract muscular contrac- tion. Splints must be long enough to hold fixed the adjacent joints, and must be so molded and padded as to lie comfortably and snugly upon the limb. We employ two distinct t}-pes of splints — those which but partially encircle the limb, leaving open spaces through which the seat of fracture may be readily inspected from time to time; and encircling splints molded entirely about the limb. Strips of wood properly padded are types of the first class of splints; plaster bandages are types of the second class, and each class of splints has its appropriate place. In general terms, we use the removable wooden splints upon fractures which have been reduced with difficulty, which tend readily to slip out of line, and are surrounded by swelling and distention of the soft parts; while, conversely, we employ the con&iing and encircling plasters (the popular term "plaster cast" is erroneous) to hold in position some fractures readily reduced and associated with little or no swelling. At the same time, if the surgeon is not employing frequent massage, he 858 MINOR SLTRGERY — DISEASES OF STRUCTURE ma}^ well dress the first class of fructures in plaster after soft union has begun and the primary swelling has subsided.' There are sundry special apparatus for special fractures, such as the familiar Buck's extension for fracture of the femur. I shall men- tion these apparatus when I come to discuss the treatment of special fractures. COMPOUND FRACTURES Compound fractures call for special and important initial treatment in order to render them sim{)le. When once simple, we treat them upon the rules already laid down. A compound fracture presents an extremely ugly form of lacerated wound, with tearing up of the soft parts, extravasation of blood, sometimes protrusion of a broken bone, and commonly a small punctured opening through the skin. We treat the wound of the soft parts, and then the fracture. The surgeon should invariably see that the patient is anesthetized for the first dressing. He must then shave and disinfect a large area of skin about the wound, employing the ordinary method of skin dis- infection; he must wash out the wound, using hydrogen dioxid and sterile salt solution; he must remove loose fragments of bone, and he must provide adequate drainage. Frequently it may seem well to him, while the wound is open, to fix the fragment by wiring. Having thoroughly cleansed and dressed the seat of fracture, he must then put up the limb in fixation splints. For this purpose splint-wood strips are commonly most convenient, for they may readily be removed when the superficial wound is to be dressed. In some cases of a simple character it may seem best to fix the limb in plaster bandages, and to cut out a window from the plaster which shall give access to the wound for its subsequent dressings. Compound fractures are less common than simple fractures; and various statistics show the proportion of compound to simple to be about as one in four; though certain bones, such as the phalanges, are more subject to compound fracture than to simple fracture. The following table, taken from Eisendrath's article, gives one an excellent idea of the relative frequency of the various compound frac- tures. The student should read this table in connection with the table on simple fractures which I gave on p. S55. Compound Fractures? Cases. Per cent. 1. Skull 525 (14.45) 2. Phalanges (upper extremity) 488 (13.43) 3. Metacarpus 272 ( 7.48) 4. Tibia 238 ( 6.50) 5. Humerus 219 ( 6.02) 6. Tarsus 203 ( 5.58) 7. Carpus 152 ( 4.80) 8. Femur 146 ( 4.01) 9. Facial bones 119 ( 3.27) 1 Plaster bandages may be fashioned so as to be removed and reapplied readily by splitting them down after they have dried upon the Umb. 2 Compound fractures entered at Boston City Hospital between 1864 and 1905. SPECIAL FRACTURES AND THEIR TREATMENT 8o9 Cases. Per cent. 10. Phalanges (lower extremity) 69 ( 1 .88) 11. Inferior maxilla ^G ( 1 .80) 12. Radius 6-1 J-;0 Ulna 04 ( 1.70) 13. Fibula «2 ( 1.70) 14. Metatarsus 2. ( 0.74 15. Superior maxilla 1^ < ^-27) Claviele 10 ( 0-27 le.Ribs 8 0-22 17. Patella 7 0.19 IS. Pelvis 6 0.16 19. Seapula 3 0.08 20. Vertebra 0.02 Sternum 1 ( 0.02) Both bones of the leg 610 (l^-70) Both bones of the arm 262 ( 7.02) "VYe may not leave the general subject of fractures and their treat- ment without referring to the possibility of the surgeon himself causing further damage to the injured limb through his own ill-regulated treat- ment. I have already spoken of malunion and the disastrous results of failure properly to disinfect a compound fracture. Another not infrequent and doleful result of treatment is the so-called Volkmann's contracture. By this term we understand a contraction or flexion of the fingers and the wrist following the treatment of fractures about the elbow-joint and in the forearm. Volkmann's contracture appears often within three or four days after the patient's accident. It is associated with loss of power in the muscles of the forearm, most commonly in young children. It is an extremely serious matter, though if we recog-nize it early, we can check its progress. The cause of the con- tracture is probably an ischemic necrosis of the muscles, dependent upon too great a pressure by splints against the soft parts. ^ Such pressure interferes with the blood-supply, so that the muscle dies and is replaced by scar tissue. I have already discussed this condition and its treatment in Chapter XXVII. Let us now consider briefly the more important— SPECIAL FRACTURES 1 AND THEIR TREATMENT Fractures of the skull and of the vertebrce are discussed in Chapters XXIV and XXV of this book. Ribs The ribs and costal cartilages are broken most commonly by blows and crushing forces. There results instant and characteristic distress: shortness of'breath, stabbing, localized pain with each respiration, and sometimes the spitting of blood if the lung be damaged. The surgeon can bring out a point of pain by manual compression of the thorax, which tends to ''start" the involved rib at the point of fracture. He 1 1 am indebted to C. L. Scudder for permission to draw largely upon his iUustrations in The Treatment of Fractures, sixth edition, 1907. _ The reader is referred also to L. A. Stimson, Fractures and Dislocations, fifth edition, 1907. 860 MINOR SURGERY — DISEASES OF STRUCTURE may feel crepitus on palpating the seat of injury,— although crepitus is by no means a constant sign in fractured ribs; but perhaps, most important of all, he can hear creaking with every respiration of the patient, by placing his stethoscope upon the suspected area. There may be distressing complications in connection with a rib fracture — compound openings and lacerations of tlio pleura and lung. I have already discussed this matter in Chaplci' .\1X. Fif^. .'i.'^'.t. Fraoturod ribs (Warren Museum"). Compound fracture of ribs, however, is not common, and far the most frequent cases are the simple single fractures whose victims present themselves at the dispensary or the surgeon's office. These people are in constant distress, and I know of few bone injuries which are capable so promptly of being relieved. SPECIAL FRACTURES AND THEIR TREATMENT 861 The treatment of fractured rib consists in immobilizing the thoracic ciige so as to limit costal respiration and force the patient to respiration by the diaphragm. There are numerous methods of im- mobihzing the chest, but by far the most effective is wrapping it in a firm swathe of surgeon's plaster; or, if a swathe be not at hand, in successive layers of plaster strips encircling the chest and laid on in the manner of clapboards. Fig. 540. — Fracture of the ribs. Starting the application of the adhesive-plaster swathe to encircle the trunk. Fixation of initial end of the swathe at the spine. Notice that the swathe is held taut as it is applied (Scudder). After this dressing, the patient is usually so comfortable that he walks about without distress, and often can return at once to his occupation. Sternum The sternum is fractured, the most frequent fracture being at the point of union of the manubrium and the body of the bone. I have seen one such fracture in the case of a football player whose manu- brium was crushed in by a blow. The symptoms are quite similar to those of fractured rib, and the deformity is so characteristic that the diagnosis is extremely easy. The patient stands in a hollow-chested attitude, while the examiner's finger sinks at once into the pit formed by the depressed fragment. The fracture is often reduced spontaneously through the patient's coughing or sneezing. Sometimes the surgeon may reduce the frac- ture by turning the patient on his back and making traction upon the 862 MINOR SURGERY — DISEASES OF STRUCTURE arms, while an assistant steadies the chest. If this nianevivcr fails, one may easily cut clown upon the fragment and elevate it. After the Fig. 541. — Position in, and method of reduction of, fracture of the sternum. Notice positions of hands of surgeon and assistant (Scudder). bones are replaced, the patient should be enveloped in a plaster swathe and kept quietly in bed for three weeks at least. Pelvis Fracture of the pelvis is frequently seen in large hospital practice, and, as Scudder points out, pelvic fractures fall into two groups — fractures of the individual bones without injury to viscera, and frac- tures at different points in the pelvic ring associated with damage to the viscera. One can palpate with fair thoroughness the whole pelvic ring, in spite of the apparent inaccessibility of the bones involved. For with a little care and patience fingers in the rectum or vagina may search out all parts of the pelvis. Moreover, the external examination alone reveals fractures often. The surgeon grasps the iliac crests and by pressure and rotation detects the fracture. The treatment of these pelvic injuries has been too much slighted and made a matter of routine. Commonly, we see the patient wrapped snugly in a plaster swathe and left to roll about in bed without further support. The plaster swathe is a valuable remed}', but its value is greatly increased if the patient be bound upon a well-fitting Bradford frame, for thus immobility is made more' certain, and the care of the patient's bowels and back is made much more easy. In case the acetabulum and pubis are fractured, it is often well to immobilize the patient's legs by the application of long confining outside splints, which shall extend from the axillee to six inches below the heels. It frequently happens that the urethra, the bladder, and other pelvic structures are torn when the pelvic bones are displaced. Extrav- asation of urine leading to peritonitis even may result. I have al- ready, in Chapters XIV and XV, discussed these complicated conditions. special fractures and their treatment 863 Clavicle The clavicle is not broken as frequently as is generally supposed, though its fracture is common enough. It stands fifth in the Boston City Hospital list, and seventh in other lists which I have consulted. When one remembers that the clavicle is subcutaneous throughout its extent, that it is a weight-bearing bone of great importance; and that every motion of the arm is transmitted to it, one sees how inevitably it is subjected to fracture by both direct and indirect violence. A collar- bone broken b}^ the victim's falling from a horse, by being stmck upon the shoulder, or by being jammed between wagons, is broken by in- Fig. 542. — Fracture of right clavicle (Massachusetts General Hospital). direct violence, and such is the nature of the injury which usually causes fracture of the clavicle. A direct violence fracture of the clavicle is not common. One sees also that indirect violence may cause green- stick fracture of the clavicle in young children — the common form of collar-bone fracture in childhood. A clavicle commonly breaks in its middle third, though direct violence, as by a bullet, may shatter it at any point in its course. With the clavicle broken, the shoulder falls foi-^^ard and drops inward so that the outer fragment of the bone is carried below the inner fragment and overlaps it in front, while the inner fragment, to which the sternomastoid muscle is attached, is tilted slightly upward. The patient stands with his head inclined to the injured side, so as to relax the pull of his stemo- 864 MINOR SURGERY — DISEASES OF STRUCTURE mastoid muscle. He relieves his pain further by sui)p(jrlins his in- jured arm in the opposite hand. If a child is the victim of a green-stick fracture of the clavicle, the characteristic attitude is nuich less marked. The shoulder droops less, while a tender swelling appears at the seat of the fracture. In the case of a very obscure fracture, a characteristic point of pain can be brought out by the surgeon's placing a hand on the outer side of either shoulder and crowding the shoulders together. The treatment of a completely fractured clavicle is not always satisfactory. The displacement can be corrected and the proper posi- tion can be mahitained, but this is not always accomplished. Obvi- Fig. 54.3. — Fracture of the left clav- icle. Modified Sayre dressing. Towel circular of upper arm held by adhesive plaster. Adhesive-plaster strap ready (Scudder). Fig. 544. — Fracture of the left clav- icle. First adhesive-plaster strap ap- plied. Shoulder carried backward. Fixed point established above middle of humerus (Scudder). ously, the indications for treatment are to carry the shoulder with the outer fragment of the clavicle upward, outward, and backward. As the old writers have pointed out, the proper position can best be secured b}' laying the patient flat on his back on a hard mattress with a small pillow between his shoulders. Few patients, however, are willing to submit to treatment in bed for this rather trifling injury. The modified Sayre dressing is usually satisfactory, however; it holds the fragments in fair position and allows the patient to walk about. This dressing is made of adhesive plaster: "Provide three strips of plaster, 4 inches wide, and long enough to extend once and a half around the body. The skin surfaces that are to come in contact — SPECIAL FUACTUUES AND THEIR TREATMENT 865 Fig. 545. — Fracture of the left clav- icle. First adhesive-plaster strap applied. Second adhesive-plaster strap being ap- plied. Hole in plaster for olecranon visi- ble. Note pad for wrist and folded towel protecting skin of arm and chest (Scud- der) Fig. 546. — Fracture of the left clav- icle. First and second adhesive- plaster straps applied. Pad in left hand. Shoulder pulled backward and elevated (^Scudder). Fig. 547. — Fracture of the right clav- icle. Modified Sayre dressing. Pos- terior view. Shoulder elevated and pulled backward. Folded towel seen in axilla for protection to skin (Scudder). 55 Fig. 54S. — Fracture of the clavicle. Method of application of a Velpeau bandage. Note the order and direc- tion of the turns 1, 2, 3, 4, and 5. Note position of the forearm and arm of the uninjured side (Scudder). 866 MINOR SURGERY — DISEASES OF STRUCTURE namely, the axilla, and chest, and forearm — are separated by compress cloth and powder. A dressing towel folded is snugly pinned high up about the upper arm. One end of the first adhesive strap is fastened loosely about the towel-protected arm with a safety-pin. While an assistant holds the shoulder well back, the arm is carried backward and held by fastening the first adhesive strap about the body. The second strap, with a hole in it to receive the point of the elbow, is started upon the posterior surface of the injured shoulder and carried under the elbow of the injured side and over the sound shoulder. The forearm is thus flexed and rests upon the chest. In applying this second strap the ^ -"%F J' \\ 1 Fig. 549. — Fracture of the clavicle and subluxation of the acromioclavicular joint. Xotice elevation of shoulder by pressure on the flexed elbow and counter- pressure on the clavicle by a bandage and a pad ( X ) placed internal to the acromiocla- vicular joint (Scudder). patient's shoulder is raised, and his elbow is carried fonvard, thus forcing the shoulder slighth' upward and backward to the fixed point used as a fulcrum. A third strap may be placed aroimd the tinank and arm to steady all in good place."' The surgeon may apply a Velpeau bandage over this dressing to give the patient increased comfort. The results of treatment are usualh' satisfactory so far as function is concerned, though it commonh' happens that some slight deformity remains for a long time. This must be inevitable in the case of any broken bone the fragments of which cannot be seized directly, manipu- 1 C. L. Scudder, ibid. SPECIAL FRACTURES AND THEIR TREATMENT 867 lated, and splintctl. For this reason it may seem well in the case of badly overriding and irreducible fragments of the clavicle to cut down upon and wire the bones. Scapula The scapula is one of the most complicated bones in the body, so that its fractures are manifold. We have to consider the great wing- like body of the scapula, the glenoid cavity, the coracoid process, the spine, and the acromion process. This bone is usually fractured by direct violence — by a crushing blow. There are no characteristic signs or symptoms of fractured scapula. The patient knows merely that he suffers great pain in the Fig. 550. — Fractured scapula. neighborhood of the shoulder and that he must support the correspond- ing arm in order to obtain any relief. The surgeon discovers grating, swelling, and tenderness, while the x-ray must be relied upon for the accurate diagnosis. If the acromion process alone be broken, the line of fracture ordin- arily is outside the acromioclavicular joint. If the fracture happens to lie on the inner side of this joint, there results a considerable flatten- ing of the shoulder. This injury may be mistaken for a dislocation of the humerus, but one eliminates this dislocation by finding the head of the humerus in the glenoid cavity. The rare fracture of the neck of the scapula, however, may well be mistaken for a dislocation of the shoulder. 868 MINOR SURGERY — DISEASES OF STRUCTURE All treatment of fructuies of the scapula is directed to raising and immobilizing the shoulder. The bone fragments cannot be approxi- mated accurately except by open treatment, which is not usually advisable. We realize that the shoulder muscles, especially the deltoid and the rotators, bind together in a natural swathe all parts of the scapula. The surgeon may, therefore, feel reasonably confident, in the case of uncomplicated scapula fractures, that he can secure a satis- factory result by enveloping the shoulder in a large thick pad of wadding, bringing the corresponding hand toward the opposite shoulder, and binding all the parts firmly together in a comfortable ^'elpeau bandage. The fragments unite quickly — usually in from three to four weeks. After removing the final dressings, the surgeon should see to it that the patient be given frequent massage and active and passive move- ments, daily if possible, and for a month at least, if he is to escape permanent crippling from a stiff and painful shoulder. Humerus The humerus is one of the im])ortant bones entering into the shoulder- joint, so that fractures of this bone may affect vitally the value and function of that joint. Practitioners sometimes speak as though the humerus were the only important bone concerned with the shoulder- Head and articular surface Surgical neck Fig. 551. — Upper end of humerus. Inner view (Scudder). joint, but our brief discussion of fractures of the scapula must have shoA\Ti that both scapula and humerus are of nearly equal value to the proper movements of the shoulder-joint. The accompanying three cuts will remind the reader of the bony outlines of these parts. Fig. 551 especially shows how the point of the shoulder is formed bv the head of the humerus and not bv the aero- SPECIAL FRACTURES AND THEIR TREATMENT 869 mion. while the close relation of the coracoid process with the humerus is a fact e;enorallv overlooked. Anatomic neck Surgical neck Great tuberosity L Jl Fig. 552. — Upper end of huiiicnis. Anterior view (Scudder). Clavicle Bicipital groove, Great tuberosity -~ of humerus Acromioclavic- . *% ular joint ^ Spine of scapula' Coracoid process Fig. 553. — View of bones of the shoulder from above. Notice acromioclavicular joint, its relations to bicipital groove and coracoid process. The point of the shoulder is made by the great tuberosity of the humerus (Scudder). There are three important types of injury to the humerus in the neighborhood of the shoulder-joint — a fracture through the anatomic neck; a fracture through the surgical neck; and a fracture at either 870 MINOR SURGEHY^DISEASES OF .STRUCTURE one of these points, associated with dislocation of the head of the bone out of the glenoid cavity. If a fracture of the humerus in the region of the shoulder be suspected, the patient should be anesthetized for proper and complete examina- tion. Without anesthesia, even though the x-ray be used, it is not always possible accurately to determine the extent of the injury; while anesthesia is of great assistance to the surgeon in the reduction and fixation of the fiagTr.ents. especially and obviously if he is compelled to treat them by the open method. It is of first importance to be certain / Fig. 5.54. — Bimanual paljjation of axilla. that the head of the bone is in the glenoid cavity. One can almost always ascertain this fact by the method of bimanual palpation — the fingers of one hand being pushed high up into the axilla beneath the pectoralis major muscle, while the fingers of the other hand press down upon the opposing fingers through the pectoralis major. If the head of the humerus is in its socket the surgeon will find nothing but the pectoralis muscle inter\'ening between his two hands, which may then be closely approximated. On the other hand, if the head of the bone be outside of its socket, it will lie somewhere within the axillary folds, and will present an abnormal and clearly felt obstacle SPECIAL FRACTURES AND THEIR TREATMENT 871 between the examining fingers. I have never known this bimanual test to fail, though I have never seen it mentioned in text-books. The other ordinary methods of examining the shoulder are well illustrated in the figures of the text. The surgeon's first interest then in making an examination of the shoulder is to determine whether the injury is a mere dislocation of the head of the bone or is a fracture of the humerus. The presenting deformities of each injury often appear quite similar. In the case of a simple didocalion, however, one sees the familiar flattening of the deltoid; while the elbow is carried out from the side, the forearm apparently is lengthened, the hollow in front of the shoulder is obliter- ated, and the subpectoral groove is lowered, as tho ficui-o illustrates. In the case of many fractures, on the other hand, the pectoral line is accentuated rather than flattened, the arm hangs limp and flail- like, while the apparent length of the upper arm is diminished as compared with its fellow\ In all cases of shoulder injury examine first the sound side and then the afTected side. Fracture of the anatomic neck of the humerus is quite common in elderly per- sons. It can be made out readily with a patient under anesthesia, but. not often without anesthesia. Crepitus may or may not be felt. The fragments may or may not be impacted ; and the fracture is wholly intracapsular. This injury often goes un- recognized; it is mistaken for a ''sprain," so that there results a permanently stiff- ened and painful shoulder. If the fracture be obviously impacted, the fragments must not be broken up, but the arm must be slung and held immobilized until the swehing of the soft parts has sub- sided. After that — say, in ten days or two weeks from- the accident — the joint should be treated actively— by passive movements, by heat, by Bier's hy- peremia, and by massage, while the patient should be encouraged to use the arm as much as possible within the limits of serious discomfort. Separation of the upper epiphysis in children is a lesion quite similar to a loose fracture through the anatomic neck in adults. ^ This fracture should be treated by immobiHzation for a varying time- three to six weeks. If the head of the bone be not dislocated from its socket, an extremely simple apparatus will suffice— a proper pad in the axilla to hold the shaft away from the side, and a firmly applied Velpeau bandage making snug the fragments. If there be marked and irreduci- Fig. 555. — Examination of shoulder. Method of palpat- ing head of humerus with thumb and fingers. Elbow grasped by other hand (.Scud- der). 872 MINOR SURGERY — DISEASES OF STRL'CTURE ble cUsplacoment of the shaft, however, especially if the head of the bone be dislocated, open treatment is necessary. In operating one may be obliged to remove the head of the bone entirely, or simply to divide or displace the parts preventing reduction; and it is never pos- sible before operating to foretell just which procedure will be necessary. We see, therefore, that fractures of the anatomic neck offer a wide range of possibility as regards the outcome of the injury. In simple cases we may look for a perfect restoration of function. In the more complicated and difficult cases we must forecast nothing better than a permanently stiffenetl shoultler, with a marked diminution in the arc of motion. Fig. 556. — Examination of shoulder. Movements of the shoulder. Normal maxi- mum abduction. Notice method of grasping head of humerus (Scudder). Fracture of the surgical neck of the humerus means properly any fracture below the epiphyseal line and within the upper fourth of the shaft of the bone. This is a common fracture and is seen at all ages. The head of the bone rests in its socket, movements are painful, crepitus is present, and there is abnormal mobility, while the arm is distinctly shortened, as shown by measuring the shaft from the acromion process to the external condyle of the humeiais. In the case of children, subperiosteal fractures of the surgical neck are not uncommon. Such fractures cannot be diagnosticated without the aid of the x-ray. Fractures of the surgical neck of the humerus are not easy of treat- ment, for approximation of the fragments is difficult to maintain. SPECIAL FKACTURES AND THEIU TREATMENT 873 Fig. 557. — Examination of shoulder. Maximum adduction. The bend of the elbow, when the forearm is flexed to a right angle, comes to the median Une of trtink (Scudder). Fig. 558. — Outline of shoulder in case of fracture of clavicle. We have taught ourselves to beheve that traction, countertraction, and manipulation will secure coaptation of the fragments. Sometimes 874 IVIINOIt SURGERY — DISEASES OF STRUCTURE we are justified in our faith, hut at the best it is hard or impossible to hold the fragments in position. The following method has long been in use at the Massachusetts General Hospital and produces a fairly satisfactory result: The hand, forearm, and elbow are bandaged firmly; a V-shaped pad (with the apex of the V ii^ the axilla) constructed of sheet-wadding is fitted beneath the arm ; and a shoulder-cap of wire or plaster of Paris is fitted over the whole shoulder and down the aiTn to the external condyle of the lumierus. The arm is then bandaged firmly to the side and the forearm is hung in a sling. Other similar methods are sometimes more effective, though they may be cumbersome and expensive. Fig. 559. — Fracture of the upper end of the humerus. Note hand, forearm, and elbow bandaged evenly and without compression; axillary pad and strap (Scudder). Whatever the apparatus used, we find that it is continually difficult to hold the fragments in place. The dressing must be removed fre- quently and regularly — at least once a week — so that the surgeon may inspect the limb and correct malposition, if possible. He must look out also for pressure sores, and will do well to have the shoulder and arm massaged each time the arm is exposed. At the end of two or three weeks soft union should take place; and fairly firm union in from four to six weeks. These fractures of the surgical neck are excellent examples of frac- tures suitable for the open treatment. Delayed union, or non-union, is not uncommon. Perfect apposition without operation is almost impos- sible. I, therefore, recommend wiring the bones in the case of persons who are not old or afflicted with any serious organic disease. SPECIAL FRACTURES AND THEIR TREATMENT 875 Fracture of the shaft of the humerus does not differ greatly from fracture of the surgical ueck, except that obliciue and spiral fractures Fig. 560. — Fracture of the upper end or shaft of the humerus. Posterior view. Note bandage to forearm and elbow; axillary pad and strap. Note shape of axillary pad (Scudder). Fig. 561. — Fracture at upper end of the humerus. Note hand, forearm, and elbow bandaged; axillary pad and strap, plaster-of-Paris shoulder-cap, sling (Scud- der). are nearly as common in the shaft as are transverse fractures. I my- self had the mortification to cause a spiral fracture of the humerus in an 876 MINOR SURGERY — DISEASES OF STRIJCTURE old m:in whoso shouklor-j(jiiit (li.slocution 1 endeavored to reduce by Kocher's method. Fig. 562. — Fracture of the shaft of the humerus. Note bandage to hand, fore- arm, and elbow; axillary pad and strap; coaptation splints and sling. Bandage does not cover fracture (Scutlder). Fig. 563. — Fracture of the shaft of the humerus. Note bandage to hand, fore- arm, and elbow; adhesive-plaster swathe holding arm upon axillary pad and cover- ing coaptation splints. Sling (Scudder). One should not fail to recognize a fracture of the shaft of the humerus. The arm is shortened and is limp; there is abnormal mobility; there SPECIAL FRACTURES A.XD THEIR TlfHAT.MENT 877 are i)aiu aiul swelling, while the gentlest mani{)ulati()n discovers crepitus. Let the surgeon bear in mind the possible involvement of the musculo- spiral nerve in one of these fractures. The nerve may become included in new-forming callus, or it may be pinched between bone fragments. If the surgeon has reason tO believe that the nerve is involved, he should cut down upon the fracture, displace the nerve, and wire the fragments. The treatment of fracture of the shaft may be simple and success- ful or may be difficidt and disappointing. Let the .r-ra}- deter- mine. Proper treatment is quite similar to that I have described for fracture of the surgical neck: anes- thesia; a proper axillar}- pad; a band- age to the forearm; splints carefully applied about the seat of fracture; a sling and a confining bandage. The progress of the case should be simple, and at a rate quite similar to that of a surgical-neck fracture. Be on the lookout, however, for wrist -drop- — a char- acteristic deformity resulting from in- jury to the musculospiral nerve. In the case of wrist-drop, change the method of treatment to the open method. c-v. ^^-r- - ., Fractures of the Elbow Interesting and important as are humerus fractures of the shoulder and shaft, humerus fractures at the lower end of that bone are even more im- portant and difficult of treatment. These low fractures of the humerus are so fre- quenth' associated with fractures of the ulna and radius that we consider this group of lesions under the caption fractures of the elhoic. The student should turn to the bony skeleton and study again the relations of the parts about the elbow-joint, making note especially of three bony points — the external condyle, the internal condyle, and the olecranon process. These are the bony points most frequently fractured. But there are two other important structures which often are damaged — the head of the radius and the coronoid process of the ulna. That is to say, we have in the elbow-joint a combination of three bones ^^'ith a remarkable variety of projections, depressions, and articular surfaces. The elbow-joint is a hinge-joint of extremely complex mechanism. It is a most useful joint. From all these facts it results that damage by fracture about the elbow-joint may have a far more crippling effect often than the apparent bone lesions might Fig. 564. — Sho^-ing effect (bowing outward) of too sliort an axillary pad upon a fracture of the shaft of the humerus (.Scudder). 878 MINOR SURGEHV— DISEASES OF STHUCTUKE lead the observer to expect. Moreover, these various Ixniy points tire associated with a great variety of muscles which tend to pull the frag- External condyle - Radial liead- nal condyle Olecranon process of the ulna Fig. 565. — Note tlie bony relations of the internal and external condyles of the humerus and the olecranon process of the ulna in complete extension of the forearm. The three points are almost in a straight line (Scudder). ments out of position when loosened by a fracture. Furthermore, damage to the synovial surfaces frecjuently results in painful and dis- Fig. 566. — Lo\verend of humerus, anterior surface. Note Unes of fracture of internal epicondyle and of fracture of external con- dyle (Scudder). Fig. 567. — Lo\ver end of humerus, anterior surface. Note lines of supracondy- loid fracture and of frac- ture of internal condyle (Scudder). Fig. 56(S. — Lower end of humerus, anterior siu-face. Note lines of T-fracture (Scudder). abling adhesions, while nearly always loosened fragments, sliding out of place and out of their normal relations, tend to block the joint and limit its proper movements. SPECIAL FRACTURES AND THEIR TREATMENT 879 AVe must be caivful, painstaking, and final in our examination of a damaged elbow-joint, and must have in mind a definite routine while making the examination. The surgeon, seated before the patient, seizes the hand of the injured ai'm in his own corresponding hand and rests the patient's forearm upon his own other forearm, supporting the damaged elbow with his hand. The surgeon's fingers supporting the elbow then investigate the following bony points: the internal condyle, the external condyle, the olecranon, the head of the radius, and the coronoid process. The surgeon then gently puts the injured arm through the motions of flexion, extension, and rotation. If there be great swelling of the elbow or great pain on manipulation, the patient should be anesthetized. Indeed, it happens commonly that anesthesia is useful as an aid in the proper reduction of the fracture. Finally, two or more x-ray plates, taken in different planes, are necessary accurately to elucidate the details of the fracture. There is an excellent old maxim that in reducing one of these fractures the surgeon should go through the movements of reducing a dislocation backward of the elbow. Indeed, great swelling mav mask a dislocation, while at the same time a fracture and a dislocation may coexist. The details of these fractures are as follows: Lesions of the Lower End of the Humerus : (a) Fracture of the internal epicondyle. (6) Fracture of the internal condyle. (c) Fracture of the external condyle. (d) Transverse fracture of the shaft of the humerus above the con- dyles. (e) Separation of the lower epiphysis of the humerus. (J') T-fracture into the elbow-joint. Lesions of the Radius and Ulna : (g) Dislocation of the radius and ulna backward wdth or without fracture of the coronoid process of the ulna. (h) Subluxation of the head of the radius. (i) Fracture of the olecranon process of the ulna. (/) Fracture of the neck or head of the radius. Besides these fractures, which appear frankly as fractures in adult bones, there are the corresponding fractures in the forming bones of children. The treatment of these lesions about the elbow-joint taxes the ingenu- ity of the surgeon, and frequently proves extremely discouraging. We endeavor to bring the fragments into apposition, and we attempt to secure union without a coincident impairment of motion. It is true, as Scudder states, that the object of treatment is to restore the elbow-joint to its normal condition; but I should qualify that bj^ sav- ing the object of treatment is to restore the elbow-joint to usefulness. It is by no means always possible to restore the joint to its normal condi- tion; but generally it is possible, in spite of extreme damage and loss of bone substance even, to bring out a useful joint. 880 MINOR SURGERY — DISEASES OF STRUCTURE At first, and so long as ^roat swelling persists, we can do little more than keep the elbow comfortably at rest on a pillow. When the swelling has subsided, we should put up the arm in a permanent dressing. We must not long delay this dressing, for ossification about the elbow- joint proceeds with gn>at rapidit}-. We should treat fractures of the internal epicondyle, of the internal condyle, of the external condyle, and T-fractures into the joint in the acutely flexed position. H. L. Smith, of the Boston City Hospital, was the first surgeon to demonstrate the value of the acutely flexed position,' and a wide experience of many surgeons has shown that this position actually reduces antl holds reduced the frac- tures we are discussing. ^ Fig. 569. — Supracondyloid fracture of tlic liuincrus. Method of reduction before applying retentive splint. Countertraction on upper arm. Traction on condyles of humerus with right hand; backward pressure with thumb of left hand. Also illustrative of method of beginning acute flexion (Scudder). Says Scudder in regard to method: "The condyles of the humerus are grasped by the thumb and finger of one hand; a finger of the other hand is placed in the bend of the elbow\ Traction is made upon the forearm, and it is slowly flexed to an acute angle. While the for(>arm is being flexed, traction and lateral pressure are brought to bear tipon the loose fragments of the humerus, to correct existing malposition." The degree of flexion will be determined by the obstruction offered by the local swelling. This acutely flexed position is maintained by an adhesive-plaster strap. There are certain precautions to be taken and dangers to be avoided in our use of the acutely flexed position; especi- ally must we inspect daily the arm during the first week, and we must see to it that proper circulation is maintained in the hand. At the 1 H. L. Smith, Position in the Treatment of Elbow-joint Fractures, Boston Med- and Surg. Jour., October 18, 1894. SPECIAL FHACTUKES AND THEIR TREATMENT 881 end of three weeks, in the average case, we can begin passive motions with the damaged elbow; we have secured good fiexion and even if perfect extension is not obtained, the imperfect extension will be a less serious disadvantage to the patient than would be inadequate flexion. Transverse fracture of the humerus above the condyles is an ugly fi-acture, and difficult to fix, for there is a constant tendency of the lower fragment to slip backward, and thus to produce a deformity which resembles a backward dislocation of the bones of the forearm. This low fracture of the humerus is fairly well held in place by the _ Fig. 570.— Left elbow in position of forced flexion. Gauze in bend of elbow. Thin axillary pad. Pad under hand and wrist. Gauze protection under forearm, held by safety-pin from sHpping. Adhesive plaster maintaining flexion. Skin pro- tected on upper arm by gauze compress from cutting of adhesive plaster (Scudder). internal angular splint, such as the illustration- shows. This splint must be padded carefully and must be strapped with two straps upon the forearm and two above the elbow, that it may be held absolutely without shifting. The outlook and rate of healing in these low fractures of the humeral shaft are quite similar to the outlook and rate of healing of higher fractures of the humerus. A dislocation backward of both bones of the forearm is easily reduced when the patient is anesthetized ; and the replaced bones may be held comfortably in position on the internal angular splint. Fracture of the neck of the radius is best treated by support on the internal angular splint. 56 882 MINOR SURC.EUY— DISEASES OF STRUCTURE Fracture of the olecranon produces a situation, and calls for the solution of a problem, of a new type. Integrity of the olecranon is Fig. 571. — Supracondyloid fracture. Obliquity of the line of fracture from be- hind downward and forward. Diagram showing deformity with elbow flexed and little sliding of fragments (Scudder). Fig. 572. — Supracondyloid fracture. Obliquity of the hne of fracture from above downward and backward. Dia- gram showing tendency to posterior de- formity if acute flexion of forearm is attempted (Scudder). r '^. essential to the strong and proper extension of the forearm ; the elbow fractures we have discussed hitherto interfere with proper flexion mainly. In these cases we have seen that a restoration of flexion is sought, but a dressing of the elbow in a flexed position is not suitable for a fracture which involves impair- ment of proper extension. We recall the fact that the bra- chialis anticus muscle is inserted into the base of the coronoid process of the ,^^.. ulna; that the triceps muscle is in- tm^ """•^i^'^ ' '^m serted into the posterior part of the upper surface of the olecranon and into the fascia of the posterior surface of the forearm, and that the small epiphyses of the olecranon unite with the shaft about the sixteenth year. The olecranon is usually bi'oken by great violence, and at a point from one to two inches from its tip. Thus the elbow-joint is always opened when the olecranon is frac- tured. Sometimes there is a marked defoimity and a depression between the bone fragments, into which depression one's examining finger sinks; or there may be little or no separation of fragments. Fig. 57.3. — Third strap is necessary to hold the splint close to the flexed elbow (vScudder). SPECIAL FKACTLKES AND THKIK TREATMENT 883 The treatment of an olecranon fracture depends somewhat upon the extent of separation of the fragments. If the fragments He close together, the arm may be dressed satisfactorily, and most comfortably for the patient, in the right-angled splint; but if there be obvious separation, the arm should be extended straight and should be bound upon a long splint reaching from the axilla to two inches beyond the finger-tips; while the small upper fragment of the olecranon should be secured and held down in place by a special adhesive strap. If it be found impossible by this means to bring the upper fragment into proper Fig. 574. — Fracture of the olecranon. Arm in extension. Long anterior splint. Note pad and strap above olecranon fragment; pad in palm of hand (Scudder). position, the surgeon will do well to cut dowm upon and to wire the fragments. If the fracture is a compound fracture, the surgeon must take special pains as a preliminary step thoroughly to disinfect the elbows-joint, after w^hich he may wire the fragments. Such are the main points in the diagnosis and treatment of fractures about the elbow-joint. A word about old neglected fractures of the elbow-joint or malunion in spite of treatment. These are peculiarly difficult cases, which fall into that class I have alread}^ described as calling for most careful consideration and consultation prior to any radical operation. 884 MINOR SURGERY — DISEASES OF STRUCTURE The classic operation for old crippling deformities of the elbow-joint (usually ankylosis) is a complete excision or removal of the joint and adjacent broken bones. This leaves the patient with a flail-joint, but generally with a strong and serviceable arm. Another method of operating is that advocated by J, B. Murphy, who constructs a new joint by separating the fused and adherent fragments of bone, and then interposing between them strips of fascia turned down from the arm, from which fascia it comes about that there develop new joint surfaces resembling synovial surfaces. Sometimes the joints thus formed are but little inferior to normal joints. Fractures of the Bones of the Forearm These fractures are both complete and incomplete — green-stick fractures of these bones are not uncommon in children. Whatever the nature of the break, the arm cannot be used without pain. There may be considerable bowing and deformity, or the defoi-mit}' may be slight. There is usuallv some shortening, and the arm hangs flaccid Fig. 575. — Fracture of both bones of the forearm. Ulnar view of the anterior and posterior splints. Note length of splints and position of straps. Straps of the internal right-angled splint, 3 and 4 (Scudder). and useless. The fracture is generally either in the middle or lower third of the forearm, while if both bones be fractured, the break in the ulna is somewhat lower than is the break in the radius. Crepitus is usually obvious except when the fracture is of the green-stick variety. The treatment of fractures of both bones of the forearm is more difficult than at first would appear, because even after splints are applied the pull of the long muscles tends constantly to cause over- riding at the seat of fracture, with a consequent shortening. At the same time there is apt to result delayed union or non-union; while the displacement of the fr^^ments narr-^ws the interosseous space and SPECIAL FllAfTURES AND THEIR TREATMENT 885 may result in a fusing together even of all fou]- of the fragments; so that subsequent rotation of the arm becomes impossible, and the usefulness of that limb is greatly impaired. Green-stick fractures cannot be straightened successfully. Such frac- tures must be made complete fractures by the surgeon, ^vho accomplishes this by bending the arm in the direction of the original breaking force. For fractures of both bones of the forearm we may use a plaster- of-Paris bandage or anterior and posterior splints. Commonly, the patient should be anesthetized, and painstaking care must be employed to insure perfect bone apposition through traction upon the lower fragments. The arm should be put up in a supinated position, as Fig. 576. — Fracture of both bones of the forearm. Proper position of arm in sling. Note hand is unsupported by sling and arm rests on ulnar side. Xotice height of arm (Scudder). thus the greatest space between the bones is maintained. In order to secure a proper fixing of the fragments in one of these fractures the adjacent joints also must be immobilized— the elbow by an internal angular splint or by plaster, and the wrist by anterior and posterior splints or by plaster. I prefer to use the right-angled and wooden splints for the first ten days after the injury. Such splints can be removed more readily for inspection of the arm than can plaster-of- Paris splints. The healing of properly treated bones of the forearm is rapid. Adult bones are sound in about four weeks. The bones of children are often sound in two weeks; but children should not then be released from splints, for they may refracture their bones at the seat of the fresh union. 886 MINOR SURGERY — DISEASES OF STRUCTURE A fracture of the shaft of o)ic of the forearm bones only is easily treated, and on lines laid down in the preceding paragraphs. When one bone only is broken, its intact fellow serves as an additional splint. Non-union of bones of the forearm is fairly conimon. Fracture of the head and neck of the radius is recognized to-day as a not infrecjuent injury. The x-ray shows it, though it is obscure to the surgeon's touch. Fracture of the head alone is intracapsular. The fragments may remain in place, or may be crowded into a remote part of the joint, where they must be sought and removed with difiicidty through operation by the open method. Treat this fracture of the radius head, if simple and not complicated, by fixation in a right-angled splint, and look for prompt union with a useful joint. Fracture of the coronoid process of the ulna is associated with a backward dislocation of the uhia, and is rare. Suspect the presence of this fracture in every case of dislocation backward of the elbow, and confirm the diagnosis by the .r-ray. This coronoid fracture may prove extremely troublesome. If. the displacement be slight, the position good, and flexion satisfactory, we may look for prompt union and a useful elbow through the employment of the right-angled splint. If there be considerable displacement and locking of the joint by the fragment, we must open down upon the bone and remove the frag- ment. CoLLES' Fracture Colles' fracture was described first by Abram Colles more than one hundred years ago. The fracture of which Colles wrote was a fracture of the radius within an inch and a half of its lower end — a fracture loose Fig. .577. — Colles' fracture. Note "silver-fork" deformity. or impacted, and characterized by the so-called silver-fork deformity. It must not be confounded with the Barton fracture, in which case the deformity is the reverse of the Colles, the forearm bones riding over the carpus instead of under the carpus, as in Colles' fracture. Of recent years a variety of fractures concerned wuth the bones of the carpus have been studied — fractures which, before the day of the x-ray, frequently were mistaken for Colles' fractures. As Scudder insists, SPECIAL FKACTUKES AND THEIK TREATMENT 887 in nil cases of cUmiagc to the wrist the surgeon should first study care- fully the uninjuretl wrist, that he may compare it with its damaged fellow. We must remember that normally, when viewing the wrist from the front, we see the base of the thenar eminence to be lower than the base of the hypothenar. Normally, the styloid process of the ulna is obvious with the marked depression below it; while on the radial side one observes the backward curve of the radial shaft from the ./ Fig. 578. — Colles' fracture. Crowding the fragments together for diagnosis. point where the radial styloid joins the shaft. One should put the patient through the normal movements of the hands, wrist, and arm, flexion, extension, and rotation. Then we observe the abnormalities of the damaged arm; the wrist appears unnatural; in extreme cases we may see at once the familiar silver-fork deformity; the thenar eminence is higher and nearer to the wrist than normal. The whole hand is somewhat abducted and the styloid process of the radius is no longer found on a level lower than 888 MINOR SURGERY — DISEASES OF STRUCTURK the styloid of the uhia, but at the same level or at a higher level even. Sometimes the ulnar styloiil is fractured, in Avhich case the i-elation of these two points appears normal. One may often elicit pain l\v palpating the end of the radius. In case of a doubtful fracture^ an excellent test is to seize the patient's hand, and, while supporting his arm above, to crowd the hand gently Fig. 579. — Dorsal dislocation of the wrist. Note deformity at wrist-joint — neither above nor below it (after Helferich) (Scudder). upward. This invariably will bring out a point of pain near the lower end of the radius if a fracture exists. If there be a sprain merely, this crowding upward of the hand gives relief rather than pain. In Colles' fracture the fragments may be impacted or may be loose; and the exact condition of the radius, as well as of the other bones about the wrist, is faithfully demonstrated by the x-ra3^ Fig. .580. — Dorsal dislocation of the hand at carpometacarpal joints. Note deformity below wrist (after Helferich) (Scudder). Dislocation of the wrist must not be mistaken for a Colles fracture. A fracture of both the forearm bones near the wrist appears as an exaggerated Colles', but the crepitus of the two bones readily is dis- covered. In persons under twenty-one years of age separation of the lower epiphysis of the radius simulates a Colles fracture. The damage SPECIAL FRACTURES AND THEIR TREATMENT 889 is less grave generally than is a Colles fracture, although the treatment of the two conditions may be similar.^ The treatment of Colles' fracture has been a subject of interest and controversy for one hundred years. A broken wrist is a serious Fig. 581.— E. M. Moore's dressing for Colles' fracture. matter, for though the bones may unite well, they may not unite accur- ately, so that the resulting malunion causes stiffness of the wrist, inter- Fig. 582.— vReduction of Colles' fracture. Note position of hands in forcibly hyper- extending the lower fragment; breaking up impaction (Scudder). ference with the motions of the tendons and joint surfaces, and a distress- ing and permanent crippling of the hand. One's endeavor then is 1 E. M. Moore taught correctly, forty years ago, that a displaced radial epiphysis, after reduction, is successfully and easily treated by wrapping a single two-inch strip of adhesive plaster about the wrist — not overlapping it on the ulnar side; the arm is then supported in a narrow sling bandage. The hand naturally falls toward the ulna, and maintains the bones in position. I have employed Moore's method with satisfaction. 890 MINOR SURGERY — DISEASES OF STRUCTURE carefully to reduce the fracture, breaking vp the imfaction if one exists, to secure the fragments properly immobilized, and finally^ — a matter of the greatest importance — to relieve the hand of the confining splints at the earliest possible moment consistent with fixation of the fi-agments. We anesthetize the patient; we drag down the hand, turning it slightly into abduction (or ulnar flexion), carefully mold the bones into position, and fix the parts firmly in two splints, as the figure illustrates. Fig. 583. — Reduction of Colles' fracture. Nf>tf gras|) upon forearm and the lower fragment of tlie radius, traction and countertraction being made; breaking up the impaction (Scudder). An interesting and important consideration in the treatment of Colles' fracture is the care of the hand during the two or three weeks of convalescence. Union is almost always prompt, and displacement of the fragments after a week is extremely improbable. For this reason we may begin early the gradual removal of splints, lightening the apparatus and employing massage. After one week I get rid of the Pig. .584. — Reduction of Colles' fracture. Note position of the thumbs and fingers. Lower fragment is pushed into place, while counterpressure is made by the fingers upon the upper fragment (Scudder). anterior splint, and hold the hand in a single posterior splint during the second week. At the end of this fortnight the posterior splint is removed, and a short dorsal splint, with an anterior pad. is secured upon the wrist, which is hung in a narrow sling. This splint in turn may generally be renewed at the end of the third week, when systematic, skilful daily massage of the arm, elbow, WTist, and hand is begun, and SPECIAL FRACTURES AND THEIR TREATMENT 891 is' continued until the puticnt's strength is restored. We encourage a noi-mal use of the released fingers in the second week, or as soon as the first heavy dressing is removed. Old Colles' fractures, neglected and badly united, offer a serious problem to the surgeon. If the patient be young and vigorous, an operation may give him a useful hand. If the patient be old and the jTjo- 585. — Fracture o tne forearm near the wrist-joint. Notice wrinkles m the straps" The straps are loose from the pressure of the two splints together. Thus is illustrated the fact that the straps should retain splints m position without ex- erting much pressure (Scudder). injury of long standing, we may be able to do little more than relieve the pain and correct deformity. H. A. Lothrop describes a_ useful operative technic : ^ Approach the damaged bone from the radial side and isolate the soft parts; with a small drill perforate the bone at several points in the line of union, and complete the new fracture with a chisel. Then trim off the fragments and approximate them carefully. If the ulna is so long as to interfere with correction of the deformity, Fig. 586.— Posterior spUnt, three straps, and pad at the seat of fracture. Note com- fortable position of forearm and hand (Scudder). that bone may be shortened by excising a small section about two inches from the joint. Then reduce and fix the fragments in the usual manner after having closed the wound, and treat the case as an ordinary fracture of both bones of the wrist. Fractures of the Carpus Fractures of the carpus are frequently mistaken for sprained wrist or for Colles' fractures even. Now that we have the x-ray, such mis- 1 Quoted by C. L. Scudder, ibid. 892 MINOR SUUGEKY — DISEASES OF STRUCTURE tukt's should never i)e made. Damage to the carpus occuis commoiil'J from ii fall upon the extentled hanil. It may l)e that some of thd smaller bones of the carpus thus become dislocated, but the conmion carpal injury is a fracture of the scaphoid. Our x-ray tracing shows how the scaphoid lies against the articulating surface of the radius, and thus takes the weight of the body in the case of a fall. Surgeons see two types of scaphoid fracture — the acute and the chronic type. The acute fracture causes pain and tenderness in the wrist, over the scaphoid, together with swelling, spasm, and a loss of function. If we ascertain the nature of the damage at once, we may correct it by fixing the hand in a splint for two or three weeks; and we follow up this treatment by active and passive movements and by massage. The chronic cases are brought to the surgeon because of a long- standing weakness of the patient's wrist and pain when his hand is — Soaphoid fragment — " Scaphoid Jragment — i- Radial fissure Fig. 587.— Case. Fracture of the scaphoid and fissure of radius (.r-ray tracing) (Balch) (Scudder). overextended. In such cases one finds the wrist movements to be limited, and spasm to be present in the extreme of motion. There are swelling on the radial sitle and tenderness over the scaphoid, while the x-ray discovers a fracture, usiuilly transverse, across the bone. E. A. Codman has worked out the proper treatment for these cases. If rest and massage do not improve the condition, cut doAAii upon the scaphoid from behind and remove the smaller fragments of bone. One should not remove the whole bone if such removal can be avoided, for loss of the whole scaphoid leaves the wrist permanently weak. Fracture of the Metacarpal Bones The third and fourth metacarpal bones are the metacarpals com- monly broken, and they are broken by indirect violence usually, a SPECIAI. FllACrrUUES AND THEIR TllEATMENT 893 blow upon the knuckles, such us may happen through a straight thrust in sparrhi"- There is a characteristic deformity, as the photographs show The dorsum of the hand is swollen, and the knuckle ot the damaged bone is sunken, while the end of the lower fragment otten A B !?,•„ '^ss A Fracture of neck of fourth metacarpal bone. Swelling of finger and t"ucM'-"ltSkthS Ipped downward toward the palm. B, Normal hand. Line of knuckles shown. Contrast with A (Scudder). can be felt in the palm, and there is pain, with crepitus. Do not mis- take this iniurv for a dislocation. It is not aLays easy successfully to treat a fractured metacarpal. We reduce the fracture by traction and pressure, and support the hand and forearm upon an anterior splint, with a pad m the palm of the hand and a pad over the dorsum. If this apparatus does not hold the fragments in position it may be well to employ a simp e traction apparatus with adhesive straps and rubber tubing as the ut illustrates Fracture of the second metacarpal may be well treated by binding the finger over a roller bandage. 894 MIXOK SUUGEKY — DISEASES OF STRUCTURE Bennett's Fracture} — In 1881 E. H. Bennett, of Du))lin, described a peculiar fracture of the metacarpal of the thumb. This fracture has come to be known as "stave" of the thumb. It is a fracture of the proximal end of the bone; oblique and into the trapezium joint. The metacarpal bone is disphiced backward, and 1^. .I'.Hi. - I'raftun- of tin- in-ck of tli<.' mtdihI iiiciacaijial. .Mi-i!,(.ii (,\ M-cuiing extension. Xote adhesive plaster, rubber tubing, peg, padding to tinger, pad over proximal fragment. Coimterextension by adhesive plaster about wrist. Ready for the application of a bandage (Scudder). the fracture may well be mistaken for a dislocation at this joint. Some- times the fracture through the bone is transverse mereh' and does not open the joint. For such a simple case any immobilizing apparatus will sufhce. Samuel Robinson describes a useful device for correcting Fig. 501.— Fracture of the finger. Fig. 592. — Finger sphnt of copper Wooden splint apphed to the palmar sur- wire applied (Scudder) face. Note straps and length of splint (Scudder). and holding the worst form of the Bennett fracture — an apparatus of plaster of Paris, combined with extension and side splints. The apparatus should remain in place for about two weeks. ^Samuel Robinson. The Bennett Fracture of the First Metacarpal Bone. Diag- nosis and Treatment, Boston Med. and Surg. Jour., February', 27. 1908 SPECIAL FllACTUHES AND THEIR TREATMENT 895 Phalanges Fracture of the phalanges is so apparent that it scarcely needs desciiption; though occasionally the fracture may be a mere crack, when the a--ray alone can demonstrate it. Ordinarily, however, the bones, lying close under the skin, may easily be palpated. In the treatment of these phalanx fractures one must take every pains to see that the delicate and important mechanism of the fingers be not seriously disturbed. A perfect alignment of the fragments must be maintained, and, as Scudder says, rotation of the lower fragments upon its long axis must be guarded against. In case of great swelling a temporary dressing upon a long palmar splint will suffice, but when the swelling has subsided the surgeon must apply carefully a small Fig. 593. -Palmar wooden thumb splint Note shape, pads, straps, position (Scudder), well-fitting splint of tin or wood. Fractured phalanges unite in two or three weeks. Compound fractures of the phalanges sometimes become infected and lead to extensive suppuration with destruction of bones. Healing eventually will take place under antiseptic dressings and splinting, but the affected finger will almost surely be stiff. In such a case a patient may choose to have his finger amputated. Femur Fractures of the femur are various in character and in location, and are difficult of treatment. Fracture of the femur is the pons asinoruvi of the surgical tyro. The complicated upper end of the 896 MINOR SURGERY — DISEASES OF STRLCTUKE femur is the part most frequently broken, while its close relationship to the hip-joint renders its proper treatment essential, if permanent crippling is to be avoided. We must recall certain lines, angles, and triangles which are useful in studying damage to the upper end of this bone. These lines are illustrated by the figures. Nelaton's line especially is useful. We determine it by stretching a tape from the anterior-superior spine of the ilium to the tuberosity of the ischium. Normally the top of the great trochanter lies just below this line about opposite to the sym- physis pubis. The internal condyle of the f(>mur looks in the same general direction as The head and neck of the femur. We deter- mine the relative length of the legs by measur- ing from the anterior-superior spine of the ilium to the tip of the malleolus of the tibia. Fracture of the neck of the femur is an ex- tremely important type of injury. It occurs most often in elderly persons, though it may be found at any age. In the old it may occur without any obvious traumatism — indeed it is probable that the delicate shell of bone in the neck of an ancient femur may be broken by the mere weight of the patient's body, by a slight twist, or by a trifling fall. Fracture of the neck of the femur may be loose; or may be solidly impacted, with a slight resultant shortening of the whole leg. The fracture may be within or without the capsule, but that is of extremely small importance as com- pared with the question of impaction. Im- pacted fractures unite rapidly. Unimpacted fractures may never unite. A patient the victim of fracture of the neck of the femur lies upon the ground helpless and in a characteristic attitude — the foot everted, the leg rolled outward. There is a slight fulness in the upper part of Scarpa's triangle; there is always slight shortening, which may be as much as two inches after the lapse of three or four da3's. The great trochanter is above Xelaton's line. If the fracture be loose, one feels crepitus. Never break up an impacted fracture in order to produce crepitus. In rare cases of impaction of the anterior portion of the neck, inversion of the foot takes place. Eversion is the common posi'^ion. In all cases of impacted fracture with permanent rotation of the foot the surgeon must assure himself that a didocation is not present. On such symp- toms and signs as I have named one establi.shes the diagnosis of fractured neck of the femur, remembering always that he must not manipulate the joint and handle the leg in a prolonged search for crepitus. Brvant's well-known method of measurement is u.seful: With the Fig. 594. — Femur; iieac and neck. Note structure SPECIAL FHACTl'IiKS A\D THEIR TFtKATMIOXT 897 patient lying on his buck and the limbs equally outstretched, mark upon the «kin tlie tip of the trochanter, draw a perpendicular line from the anterior-supcM'ior spine to the bed on which the patient is lying, and stretch a line from the trochanter to this perpendicular. If there is fracture of the neck of the femur this last line Avill be shorter on the affected side than on the sound side. The course and the outlook in the case of a fractured neck of the femur vary greatly — depending largely on the age, the \-igor, and the general condition of the patient. Feeble old persons with this injury fre- Fig. 595. — Vertical section of hip-joint, seen from behind. The angle which the head xmder normal conditions forms with the shaft (127 degrees) is marked out: /, Rim of acetabulum in vertical section; C, cavity of joint (exaggerated), showing the extent of the joint capsule; L, ligamentum teres (Eisendrath). (Scudder.) Fig. 596. — Measurement of lower extremity. Patient ly- ing on the back looked at from above. Position of tape, hands, and Hmbs to be noted (Scud- der). quently die from the shock, or from the confinement to bed, — being carried off in the latter case by hypostatic pneumonia. Our rule, therefore, is to have old patients sit up as much as possible^ in bed or in a chair, fixing the fracture in plaster if the fragments be loose ; while if the fracture be impacted no fixation apparatus is required frequently. The bones of the impacted cases always unite, but in the case of loose fractures permanent non-union even is not inconsistent with a useful leg, especialh' if the patient be provided with a proper ambulatory apparatus. The treatment of ''fractured hip" deserves some further con- 57 898 MINOR SURGERY — DISEASES OF STRUCTURE sideration than we have given it in the preceding paragraphs. We recognize four methods of treatment in use at the present time: (a) The method of traction and countertraction, by weight and pulley and elevation of the foot of the bed, together with lateral traction when such traction is indicated; (6) the Thomas hip splint, with or without traction; (c) forcible abduction and fixation by plaster of Paris, with or without continuous traction; (d) the method of pegging. (a) The traction method must be employed with the patient upon a proper surgical bed, a firm and narrow mattress. Rest his knee upon a pillow, fasten extension strips of adhesive plaster from his ankle to the hip; hang a five-pound weight over a pulley upon the extension strips; rotate the foot into a normal position, and raise the foot of the bed about 6 inches so that the patient shall not slide down Fig. 597. — Thomas' single hip-splint in position (Ridlon). Fig. 598. — Thomas' double hip-splint in position (Ridlon). under the traction of the pulley; steady the whole leg with long heavy sand-bags, and protect the heel, with a proper ring or other support, from undue pressure. (6) The Thomas hip splint has been a favorite with a few surgeons who claim for it excellent results. I reproduce here the figures of Ridlon ^ and refer the reader to his article, or to the admirable descrip- tion given by Scudder in his book on Fractures.^ (c) Forcible abduction and immobilization with or without traction is known as Whitman's method, and purposes to bring the bone frag- ments together and to hold them in the normal position, with restora- tion of the proper angle between the shaft and the neck of the bone. ^ Transactions of American Orthopedic Association, 1S87. 2 C. L. Scudder, ibid,, p. 342. SPECIAL FKACTUHKS AND THEIR TREATMENT 899 This method i« applicable especially to the cases of young persons in whom the angle is far more obtuse than it is in old persons. The patient is anesthetized, while his pelvis is supported by a block on, the table. The injured limb is then abducted through 45 degrees so that the fragments lie in a normal relation to each other. A plaster- of-Paris spica bandage is applied to the pelvis and thigh (including the foot in young persons). Sometimes we must flex the thigh in order more perfectly to reduce the fragments. "Traction, abduction, flexion, lifting the trochanter forward (to prevent sagging), rotation (to correct abnormal eversion or inversion of the foot), immobilization, these are the steps of the procedure." We employ Whitman's treatment in selected cases and w^e keep the plaster spica in place for about eight weeks. The weight of the body should not be allowed to fall upon the hip for many weeks thereafter, the leg meanwhile be- ing supported in a Taylor hip splint, and the patient using crutches. Whitman's method is logical and extremely attractive, and de- serves a wider application. (d) The so-called pegging method^ is a method of secondary resort only. In proper cases it is an extremely valuable procedure, but its field of usefulness is limited. In general terms we employ it in sound adults with fracture of the neck of the femur when apposition of the fragments is shown by the a:-ray to be so faulty as not to permit of proper union. In old ununited fractures of the hip also we may employ the pegging method. An ivory peg or, better, a coin-silver nail is driven through the great trochanter and through the long axis of the neck of the bone. In the case of an ununited fracture it is well to open the joint and to peg the fragments in plain view. The best incision is a straight one on the outer side of the great trochanter. We may leave the, peg permanently, or may remove it at the end of a month. The best dressing for a pegged hip is the plaster-of- Paris spica. The following rules for pegging will be found satisfactory: The affected leg is adducted; a four-inch nail is entered one-half inch from the anterior edges, and two finger-breadths from the top of the great trochanter. It is directed upward and inward, making an angle of about 70 degrees with the shaft of the bone, and is driven into the loose head. One should take a skiagraph of the joint after the pegging. Fracture of the neck of the femur in children has been discussed Fig. 599. — Illustrates the restoration of the normal angle by forcible abduction (Whitman). ^ See;.H. Augustus Wilson, Treatment of Ununited Fractures of the Neck of the Femur by the Use of Coin-silver Nails, Amer. Jour. Orthop. Surg., January, 1908. 900 MINOR SURGEKY— DISEASES OF STRLCTURE recently by a number of writers, especially by Whitman. This fracture, which is properly an epiphyseal separation, is especially important on account of its apparent insignificance, and because frequently it goes unrecognized. It results commonly from a fall on the foot, and causes a slight shortening of the leg, with a little outward rotation and Fig. 600. — Fracture of the thigh. Adhesive-plaster extension strips: long, upright, circular, and obliquely applied strips i^Scudder). a tendency to limp. The child recovers with some lameness, but years afterward may develop a coxa vara. In dealing with a child the surgeon must discinguish (by the J'-ra}-) a true hip fracture from hip disease; and treat the fracture b}' fixation and abduction in a plaster splint. Fig. 601. — Fracture of the thigh. Extension strips applied, covered by bandage. Ham-splint applied; two straps and pad in ham iScudder). Fracture of the shaft of the femur is the fracture of this bone next in importance to fracture of the neck of the femur. These shaft fractures are generally oblique, and occur in three favorite locations: (1) Just below the lesser trochanter; (2) at the center of the shaft, and (3) above the condyles. Such fractures are always due to great violence, the shaft of the femur being extremely resistant, so that extensive SPK('1AI> FRACTUUES AND THEIR TREATMENT 901 damage to the soft parts often is cuused even when the fracture is not compoum .^^ find the patient with a fractured femoral shaft lying help- less often in shock and pain; the leg rolled inward or outward, and the 'thigh deformed by a marked swelling, while crepitus is apparent. The surgeon should measure such a leg to determine its shortemng relative to the shortening of the sound leg. Measure from the anterior- superior spine to the tip of the internal malleolus. To the student familiar with gross anatomy, or to the unlearned observer even, it must seem incredible that a fractured feinora shaft could be treated by a graduate in medicine, with the result of a striking deformity and serious shortening of the leg; yet I have been a witness in an entirely justifiable law-suit brought against a reputable physician who treated for three months a fractured femur in a child of_ six years, with the result that the femur was allowed to unite at a right angle v\. fin9 Fracture of the thigh. Extension strips apphed. Cotton bandage. HaJ^lliXsTrSfpa", Id coaptation splints about the seat of fracture, btraps and buckles (Scudder). and with marked shortening, while the child walked with an ugly limp Fractures of the femur are not easy to treat. They call for constant inspection, frequent measurements, the reapplication of apparatus, ^'^'^The%!atmmt of fractures of the shaft of the femur is a subject more or less open to discussion. There are those who maintain that the best treatment is by abduction, extension, and immobihzation m a plaster-of-Paris spica extending from the toes to the «F^e of rt^^ ilium I do not feel that this is a proper dressmg for a fracture of the shaft' in the case of an adult. Sometimes it may do m the case of a restless and intractable child. Fractures of the femoral shaft are extremely difficult of coaptation and of proper immobihzation. l^or this reason such fractures should be dressed in an appara us which wall permit of frequent inspection and the correction of displacements. The familiar Buck's extension with coaptation splints on the thigh posterior ham-splint, and a long outside splint, is the apparatus which 902 -Mixoii sii{(;i;uv — diskashs of stiucti he meets the neeessities of the case. The coaptation si)liiils aie such as I have ah'eady described. They are shown in the accompam'ing figure. The ham-spHut should l)e carefully adapted to the length of the leg and to its curves, and should be heavily padded. The long outside splhit should i-(>ach from the axilla to immediately below the ankle, while the internal sj)lint should reach from the pei'ineum to just below the ankle. The illustration shows the appeai'ance of this ai)par- atus and its application. Fig. 603. — Fracture of tlie thigli. Completed apparatus, as in Fig. 602, and in addition a long outside T-splint, .straps, and swathe. A\ eights applied (Scudder). The most important feature of the dressing, however, is the extension. Extension straps are carried from one inch below the seat of the frac- ture out to a pulley, such as is figured in the text, and the foot of the bed is raised foi- counterextension, as in cases of fracture of the neck of the femur. "Buck's extension'' is a convenient apparatus for the treatment of compound fractures, as well as for the treatment of simple Fig. 604. — Fracture of the tliigh. Completed api)ar;itus with Ix-d elevated. The outside si)lint is broad and witliout the T foot-piece. The swathe is veiy snugly applied (Scudder). fractures. The complete rediu-tion of the fragments is not always immediately possible by its use, but the surgeon will observe, during the first few days of convalescence, that the affected leg gradually becomes longer until, under proper conditions and with careful employ- ment of the extension apparatus, the length of the two legs will often be found to vary not more than half an inch. The surgeon must guard cai-eftdly against malunion of the fragments SPECIAL FUACTrUES AND THEIU TREATMEXT 903 through outwiird rolution of tlic Ici; uiul foot. Thi.s outward rotation is a detail of the treatment whicli must be seeu to carefully. Fre- c[ueutly, at his morning visit, the house-surgeon will find the patient's foot turned outward and lying nearly flat upon the bed, being displayed to a right angle almost. Various methods are employed for correcting such a malposition. I reproduce here two sketches taken from Scudder. They demonstrate well the type of malposition to which I refer and a simple maneuver for its correction. Supracondyloid fracture of the femur gives rise often to an awkward relation of the fragments, and frequently to a serious deformity in the leg, for the reason that the gastrocnemius muscle rolls backward the condyles of the femur, while the shaft fragment shoots fonvard toward the patella. This results in apposition of the smooth anterior surface of the lower fragment, with the fractured end of the upper frag- ment— a position which often prohibits absolutely a firm union. Fig. 605. — Form of stirrup Fig. 608. — Diagram of section of leg and splint to prevent the foot assuming an to show how a strap carried from the back of the equinus position (Scudder). leg over the long side-splint can prevent eversion of the foot and leg (Scudder). I have had admirable success, as have many others, in coaptating and immobilizing such fragments by placing the knee in the right- angled position. One may dress the leg in the old fracture-box arranged at a right angle, or, perhaps more conveniently, one Tcnay employ in these cases a firm plaster-of -Paris bandage. It is often well, however, to operate for the reduction of a supracondyloid fracture. If the leg were mine, I should choose the operation. The surgeon, when he operates, must search thoroughly for all fragments of bone; he must remove them from the loose spaces behind the knee; must do tenotomy, if necessary, upon the attachments of the gastrocnemius muscle, and must wire the long fragments in their proper position. After such an operation the leg may be held in an apparatus of open splints for a few days until the superficial wound be healed, after which the whole leg, from toes to crest of ilium, may be secured in a plaster-of-Paris dressing. Fractures of the Thigh in Children. — At the Massachusetts General Hospital we have for many years dressed these fractures in a suspended position. This dressing is perfectly comfortable. The child lies upon a Bradford frame and has draped over him such appar- 904 MINOR SURGERY — DISEASES OV STRUCTURE atus as is figured in the text. The pulley exercises constant and proper extension; a certain amount of movement of the body is permissible, the child lies restfully, and the results of treatment are satisfactory. The prognosis of all fractures of the shaft of the femur is somewhat dubious. We can. as a rule, promise the patient a useful leg; but we cannot justly promise him always a leg without deformity, or a leg free from a certain amount of stiffness and weakness. We should keep him under observation, if he be an adult, for six months at least, and for a year if possible, seeing to it constantly that he does not bear his weight upon the soft callus in his impatience to hasten convalescence. Fig. n07. — Fracture of the femur in a child. Note Bradford frame on which child rests; the i)osition of the lower extremity. Shoulders and trunk of child held fixed by straps and swathe. Note coaptation splints, extension, weight, and pulley. A comfortable position for child. An efficient method of treatment (Scudder). Children also must be kept for at least four months under observation ; though the prognosis as regards deformity and function is generally good in their eases. We pass now to another interesting fracture, the treatment of which has of late years provoked no little discussion. Fracture of the Patella A certain class of radical operators — not well advised, I believe— have asserted that in every case of fracture of the patella the surgeon, as soon as he sees the patient, should cut down upon the bone and should suture it. There are two elements in this argument which are dangerous and objectionable; the immediate operation on a recent fracture is followed by a high percentage of infections; while the in- discriminate operating upon all types of fracture of the patella is need- SPECIAL FRACTURES AND THEIR TREATMENT 905 less. Certain fractures of the patella show very little separation of fragments and heal promptly under conservative treatment. We need not here discuss the intricate and interesting relations of the patella to the surrounding parts other than to remind the student that the patella lies entirely upon the articulating surface of the femur; that its lower border reaches as far as the head of the tibia in some cases, and never lies upon it ; that the inferior surface of the patella is an ar- ticulating surface, and is formed of two facets separated by a marked ridge, and that while the patella is a sesamoid bone within the sub- stance of the quadratus femoris tendon, it is not a bone essential to the extension of the leg, since the quadratus finds a broad insertion into the lower leg through its aponeurotic expansion entirely independent of the patella. Fracture of the patella involves always a fracture into the knee-joint. Fig. 6US. — Expectant method of treating fracture of the patella. Same as Fig. 615, with the addition of two lateral splints, padding, and straps (Scudder). The patella, like other bones, is fractured by both direct and indirect violence. The fracture by direct violence is commonly characterized by a splintering of the bone alone — sometimes into two fragments, sometimes into half a dozen or more. The surrounding aponeurotic supports, however, are not torn in such cases of direct violence, so that the bone fragments remain in fair apposition. A fracture by indirect violence, on the contrary, as when a man falls from a height and lands on his feet with knees bent, is nearly always associated with extensive tearing of the soft parts in the neighborhood of the patella. In this case the violence results in wrenching the patella in two, but a comminu- tion does not follow. The two fragments immediately become widely separated, and their approximation, without the surgeon's open inci- sion, is almost impossible. In both direct and indirect violence fractures there is marked loss of power of extending the leg, but the loss of power is greater in the case of an indirect violence fracture than in the case of 906 MixoH sruoKin' — diseases of structike a direct violence fracture. W'iihout any treiitnient of the direct violence fracture the symptoms may subside, and a fair use of the leg may be restored, but it will ahvays remain weak, with the kicking or extending force far below normal. \\\ fractures of the patella are associated with a collection of fluid in the knee-joint, for the parts about this bone are abundantly supplied with blood, which pours out into the damaged joint. There results a clot, bi-uising of the serosa, a copious serous effusion, and great swelling of the parts about the knee. From Avhat I have stated it must be obvious that the treatment of a patella fracture depends largely on the nature of the violence causing the fracture. In the case of a direct violence injury, with little separa- tion of bone fragments, the surgeon may secure an admirable result, with firm union and a sound leg, V)y following the conservative method — that is, by supporting the leg in a ham-splint for at least six weeks, and by holding the fragments firmly in -— ■'" - ~~«-«s apposition by strapping them with surgeon's plaster. Obvioush-, this apparatus should not be applied until the primary and extensive swelling has subsided. When union has been fairly established, the patient's leg may be put up in a long plaster-of- Paiis bandage reaching from the ankle to the groin, and he may then be allowed to go about upon crutches. At the end of eight or ten weeks from the time of the injury the stiff bandage should be removed, passive movements should be begun, and active massage should be employed until fair function has been restored to the leg. Unfortunately, the patella, once fractured, remains always some- what weak, so that it is a frecjuent experience to see secondary fractures of this weakened bone. Fractures of the patella by indirect violence, w^ith wide separation and great effusion into the joint, call for operative treatment in case the patient is fairly vigorous and in condition to withstand the shock of an operation and the possibility of infection. Numerous statistics, especially those collected by the late Carleton P. Flint, of New York, have demonstrated that immediate primary operation, that is to say. operation within five days of the accident, is ahvays inadvisable. Im- mediately after the accident the parts are peculiarly susceptible to infection. After five days, however, preferably about the tenth day, operative treatment of a fractured patella is reasonably free from risk. The question of method in operating upon a fractured patella '^^5ar- Fig. (iO'J. — Skctcli showin;,' line of incision for ojjeration on patella. SPECIAL FRAr'TURES AND THEIR TREATMENT 907 has agitated the profession for a great many years, and a variety of plans and procedures are advocated b}' surgeons. Especiallj- there are the champions of burj'ing wire in the fragments, and there are those who advise suturing the bone with some absorbable material. It is needless in this place to elaborate this discussion. An excellent practice, and one that I have followed with satisfaction, is as follows: Tuiti back a long crescentic skin-flap over the patella without opening the joint. Thus one removes the line of skin incision far from the field of operation, and bj' so much diminishes the opportim- ity for infection through the skin. Having exposed the aponeurosis over the patella, clean it carefully, dissect away the frayed and torn edges, expose the fragments of bone and the lacerated parts on either side of the joint, gently irrigate the joint through a soft-iiibber tube, secure perfect hemostasis, sew up torn soft parts with a lamning stitch of catgut, and approximate carefully the bone fragments by drawing them together with interrupted catgait stitches which shall include the aponeurosis and periosteum only. Close the skin incision; insert a small drainage wick, put up the limb in a firm posterior wire- splint or other similar splint, and support the freshly united bone fragments with strappings of surgeon's plaster. In this manner we secure conditions which result in prompt bony union. Commonly, at the end of two weeks I substitute a plaster-of-Paris splint for the primary dressing; get the patient about on dutches for a couple of weeks, and then four weeks after the operation begin passive move- ments and massage of the joint. I am satisfied that the earlier pas- sive motions and active treatment of the joint advocated by certain writers are hazardous, and in the long iTin unsatisfactoiy. Some sur- geons prefer silk or kangaroo tendon to catgtit in suturing the bone. I am quite reach* to admit the value of such suture materials. A fractured patella treated on the lines I employ should remain firmly united, and the leg should become nearly as useful as formerly. Vnfortimately. we cannot promise the patient a perfect restoration of function. It is rare to find a case of old patella fracture 3'ears after- ward to be free altogether from some slight stiffness and weakness of the joint. I am unable to corroborate Scudder's optimistic statement that "at the end of three months the knee should be functionally perfect." Fractures of the Leg The bones of the leg are in some measure analogous in their relations to the bones of the forearm, but the analogy is by no means perfect. The tibia is the large and important bone of the leg; the fibula is rela- tively far less important than is either of the bones of the forearm. The tibia alone enters into the anatomy of the knee-joint, but both tibia and fibula are concerned with the ankle-joint. The bones of the leg- admit of no rotation, as do the bones of the forearm; indeed, one may regard the two bones of the leg as mortised together in a fashion, and as forming one broad and solid support for the body. One recalls the 908 MINOR SURGERY — DISEASES OF STRUCTURE fact also that the front edjio of the tibia is subcutaneous practically throughout its extent; -while the fil)ula is deeply buried in muscles Fig. 610. — Rupture at tubercle of tibia. Operation — step 1 (author's case). except its head, and the external malleolus, which is subcutaneous for a space of some three or four inches above the ankle. Fig. Gil. — Operation on tubercle of tibia — step 2. Note ligamentum patell-r torn off and turned into joint (author's case). The tibia suffers fracture more freciucntly than does the fibiUa; both bones are often fractured at the same time, while fracture of the SPECIAL FRACTURES AND THEIR TREATMENT 909 fibula alone, except just above the ankle, is rare. Most of the fractures of one or both bones are due to direct violence. Injury to the tubercle of the tibia is not very uncommon. It is an accident of vigorous young men, and is due to a starting of the upper epiphysis of the tibia, usually from indirect muscular violence. This injuiy is followed by acute pain at the point of damage, with some little swelling, tenderness, and a marked diminution of the power of extension. Then there follows a more or less permanent sense of weak- ness, with a return of pain on exertion. As Osgood says: "The condi- tion presents no complete loss of function, but is a severe handicap to the active athletic Hfe which this class of patients wish to lead." Fig. (il2. — Operation on tubercle of tibia — step 3 (author's case). "We can bring about a cure by immobilizing the knee-joint for from three to six weeks; and if this simple method fails, we can secure the damaged fragment by pegging or by sewing it down to the periosteum. A frank fracture of one only of the bones of the leg is not always obvious, for the sound bone may act as a splint, and so steadj^ the damaged bone as to mask the ordinary evidences of fracture. Of course, a fracture of both bones, or a compound fracture will readily be determined. Generally, the experienced surgeon discovers abnormal mobiHty and crepitus by seizing the leg firmly above and below the point of injury and cautiously manipulating the parts. He can bring out distinctly the point of pain by appro ximaing strongly his two. hands. His diagnosis of fracture will be confirmed by the a;-ray. It is needless to dwell upon the famiHar symptoms — pain, swelling, loss of power — ^which are common to aU fractures. In discussing the subject of treatment of fractures of the leg Scudder 910 MINOR SrUGHRY — DISEASES OF STRUCTURE adopts four tlivisioius or groups, which are U(hniriible, for the sake of systematic discussion : 1. Fractures with little or no swelling or displacement. 2. Fractures "svith considerable swelling. 3. Fractures with a displacement of fragments difficult to hold corrected. 4. Open fractures. Fractures with little or no swelling are fractures of one bone only, as a rule. The surgeon may elevate the leg for a few minutes in order to diminish what slight swelling is present, and then he may dress the limb in a plaster-of-Paris bandage, including the ankle and the knee; or he may employ a temporary dressing with open splints for the first week and then substitute for this pi-imary dressing the plaster-of-Paris bandage. Fractures with considerable swelling and fractures with a displace- ment of fragments difficult to hold corrected require far more careful investigation and treatment than do fractures of the preceding group. Fig. 613. — The Cabot posterior wire splint padded completely. Note the foot- pad of pasteboard covered by cotton cloth pinned to the foot-piece of the splint for greater security (Scudder). The swelling is due to an effusion of blood and l}-mph. Both bones may be involved. The skin about the scat of fracture may be the site of numerous blebs of varying sizes, while there may be marketl shortening of the leg. It is obviously unwise to dress a leg so damaged in a tight immobilizing plaster bandage, since the circulation may be thus interfered with, and gangrene of the foot may result ; or swelling may subside so rapidly that the plaster splint will fail to hold the parts in place, and a marked deformity gradual!}' will develop. Fcr such reasons it is advisable to put up the limb in a temporary dressing until the great swelling has subsided. At the Massachusetts General Hospital it has long been our practice to support one of these fresh fractures in a pillow splint, reinforced with firm wooden splints on the sides and beneath the pillow. This is an admirable and com- fortable dressing, in which the patient should lie until the ]3rimary swelling has subsided. We then employ as a permanent (h-essing the so-called posterior wire splint of A. T. Cabot — a splint which is well demonstrated by the illustration in the text. Numerous other forms SPECIAL FRACTURES AND THEIR TREATMENT 911 of apparatus have been used, especially the well-known molded felt and plaster splmts. The leg having been dressed and firmly secured, 1 recommend the use of the hammock or sling. This raises the leg from the bed, and holds it comfortably supported and immobilized, while through its use the patient is enabled to move his body about slightly, and thus to relieve the strain of the dorsal position. If the leg sling be not used, the patient is not able to move at all without pain in the leg. Under the best of circumstances it is rare to secure by the closed method of treatment a perfect approximation of the damaged bones. Fig. 614. — Methods of supporting the foot in fractures of the leg when using a posterior spUnt: a, Padding beneath tendo AchiUis; b, ring under heel; c, sling of adhesive plaster (Scudder). The heel will drop, the foot will become everted, and the calf-muscles will exert undue traction, so that in one fashion or another the bone fragments are constantly being pulled out of position. We employ various devices to obviate these difficulties. We pad the heel, we roll in and secure the foot; while one of the best of all maneuvers is the application of the short Desault splint, which exerts a continuous uni- form traction upon the foot and aids materially in securing a reduction and a fixation of the fragments. The figure copied from Scudder shows how the screw at the foot exercises traction, while the long splints, with their plaster straps at the top, enforce a permanent counter- traction. 912 MINOR SURGERY — DISEASES OF STIU ( TrUE For the hou.se surgeon there is probably no one subject in the field of fractures so common, so difficult, and so interesting as this sul)ject of fractures of the leg. The problem is one recjuiring for its successful solution constant patience and a stud}- of the invalitl's comfort. Again I refer the reader to the admirable woi-ks of L. A. Stimson and C. L. Scudder on this topic. Fi^. (i !.">.- Iracturc of tli(_' !(■<:. Cabot poaterior wire splint padded projjeily according to the cur\es of tlie normal leg. A'otice that the heel is free from the splint (Scutider). Open or compound fractures of the leg offer many opportunities for the ingenuity of the surgical dresser. In one of the early para- graphs of this chapter I discussed in general terms the compound frac- tures. The tibia suffers from compound fracture more commonly than does any other one of the important long bones, for the tibia is placed immediately beneath the skin. The surgeon or the assistant who first sees and dresses a compound fracture of the leg is responsible for the life of the patient, because it rests with this attendant, by his primary Fig. 616. — Fracture of the leg. Cabot posterior wire splint, side and posterior wooden splints held \)y straps. Adhesive plaster to foot and ankle (Scudder). care to secure asepsis, wound healing, and bone union; or it remains for him by his inefficiency to lead the patient into a condition which shall conduce to infection of the wound with a possible loss of limb or life. In making the primary dressing the surgeon should operate with the patient anesthetized; he should wash the leg with soap and water, and scrub it with gauze sponges and the nail-brush after the hair of RPEC'IAI. FRACTURES A\D THEIR TREATMENT 913 the whole leg has licen thoi-oughly shaved away. Then he completes his cleansing of the parts by scrubbing the leg with liquid chlorinated soda (1 : 20) which removes effectually all grease and oily dirt. The surgeon then turns his attention to the damaged soft parts. He enlarges the wound sufficient!}- to permit of a digital explora- tion of the deeper tissues; he washes out the clots and detritus with a long-sustained irrigation of hot salt solution ; he checks hemorrhage, and com- pletes his cleansing by soaking the parts in hydrogen dioxid and washing that away finally with another long douche of hot salt solution. If the bones are badly splintered, he removes the loose fragments; if the larger fragments are not brought easily into apposition, he secures them with silver wire ; he then in- serts a small drain deep in the leg, applies an ordinary dry aseptic dressing to the outer parts, and puts up the leg in a permanent posterior wire splint such as I have described. Pott's fracture of the fibula, like CoUes' fracture of the radius, is one of those familiar and much-talked-of frac- tures of which the literature is enormous. In Chapter XXVI I have already de- scribed how Percival Pott broke his ankle, studied the ailment, and then told about it. In spite of much talking and writ- ing, however, one finds that students are curiously ignorant of the exact nature of Pott's fracture. Pott's fracture is a fracture of the fibula, associated with an outward displacement of the foot. Scudder put it neatly thus: ''The lesions ... in this fracture are a rapture of the internal lateral ligament, a fracture of the tip of the internal mal- leolus, a separation of the lower tibio- fibular articulation, an oblique frac- ture of the fibula two or three inches above the tip of the external malleolus, a fractureof the outer edge of the lower end of the tibia. . . . Mechan- ism: As a foot is abducted, the strain is felt at the internal lateral ligament and at the inferior tibiofibular interosseous ligament, and these give way. If the force continues, the fibula breaks. If the force still continues, the internal malleolus is pushed through the skin and an open fracture results. If the internal lateral ligament holds 58 F i g. 617. — Short Desault splint for the appHcation of trac- tion to lower leg fractures. Frac- ture at X. Extension strips u-p from the fracture are fastened at the top of the sphnts. Ex- tension strips down from the fracture are fastened to the foot- piece. Tightening the screw at foot-piece makes traction and countertraction (Scudder). 914 MINOR SUHGEHY — DISKASES OF STKLCTLRE against this lateral force, the tip of the iiiteniul nmlleolus may be pulled off." One would suppose that the s3-mptonis of this complicated injury would be obvious enough, yet it frequently happens that physicians Fig. 618. — Packling the Cabot posterior wire splint. Applying sheet wadding. Tlie shape and proportion of the Cabot splint are apparent (Scudder). treat Pott's fracture as a sprained ankle. The deformity is fairly characteristic, however, and the swelling is great. Compare the two feet and you will see the damaged foot dropping somewhat lower than Fig. 619. — Pott's fracture of left ankle. Method of examining ankle. Lateral mobiUty shown. Note the grasp of the foot and the leg (Scudder). the sound foot as the patient lies upon his back. Seize the damaged leg firmly in your hand, about 4 inches above the ankle, and squeeze the two bones of the leg together. You will bring out a sharp point of characteristic pain at the seat of the fracture in the fibula. Sometimes SPECIAL FRArTlRES AND THEIR TREATMENT 91^ you may feel the splintered tip of the internal malleolus. The a:-ray tells the story. Treatment of this form of fracture is entitled to the greatest respect, for treatment ill advised, half-hearted, or inappropriate may land the surgeon in the court-room. The first object of treatment is to reduce the fracture of the fibula by inverting the foot so as to restore its normal relations, and to bring the astragalus back again against its opposing articulating surface at the end of the tibia. It may happen, as I have Fig. 620. — Pott's fracture. Dupuy- tren's splint. Note length of splint; posi- tion of straps; arrangement of padding; space betw^een foot and splint (Scudder). Fig. C21. — Pott's fracture. Dupuy- tren's splint. Note serrations of splint and turns of bandage adducting foot (Scudder). stated elsewhere, that damaged tendons or the soft parts will interfere with a proper approximation of the fibula fragments. In such cases the surgeon must transform the simple fracture into a compound fracture at the point of fibula fracture; and he should wire together the fragments. Having reduced the fracture, how shall we retain the foot in place? Constantly it tends to fall outward. I have been satisfied for years with the familiar splint of Dupuytren. This holds the foot and leg 916 MINOR SUKGKKV — DISEASES OF STIUCTIKE comfortably, and secures a positive and constant inversion of the foot. The posterior wire splint of Cabot or a plaster bandajic may do well enough for mild cases of Pott's fracture, but they jarely suffice for the extreme forms. Should the Pott's fracture be originally a compound fracture with an opening into the ankle-joint, the surgeon shoukl tlress the foot with the greatest care, should cleanse thoroughly the jcunt. should wire the fibula, should place the limb upon a posterior wire splint, and should give a guarded prognosis. Rarely, and under the best conditions, I have seen these injuries lead to severe and extensive suppuration necessitating amputation of the foot. Modem methods of fighting infections — the employment of proper opsonic vaccines and constant antiseptic lotions — are rendering these fomiidable compound injuries less serious than they were ten years ago. Bones of the Foot Fractures of the bones of the foot, especially fractures of the tarsus, frequently can be determined through the use of the x-ray only. These fractures are often due to falls from a height, or to such a crushing force as is exerted by a heavy wagon-wheel rolling over the foot. Fre- quently the lesion is compound. One may discover crepitus, but the great swelling of the foot may obscure the grating. Injuries to the foot, whether of the bones or soft parts, differ markedly from injuries to the hand in this respect — that except in the case of children these lesions heal slowly. The circulation in the foot is sluggish as compared with the circulation of the hand, so that a fractured bone or an ex- tensive cut of the foot frequently will require two or three times as long for its healing as a similar lesion in the hand. For such reasons damaged feet must be watched and treated for a long time, and, so far as possible, the patient must be ad^-ised and encouraged to keep his bed, frequently for weeks, rather than to get up and move about on crutches as his inclination prompts him. One of the tarsal bones commonly fractured is the astragalus. Its fracture is often mistaken for a simple sprained ankle. Discover it with the x-ray. Dress it in a plaster-of-Paris bandage, running from the toes to the knee. Remove the plaster at the end of two weeks. Employ proper massage for a month, when a satisfactory residt will be secured, though the foot may not be perfectly comfortable until four or even six months have elapsed. The OS calcis, or heel bone, is often fractured, especially by a fall. Sometimes the fragments are greatly separated through being pulled apart by the gastrocnemius muscle. The x-i'ay will show the extent of the damage. In order to reduce the fragments it may be necessary to perform tenotomy of the tendon of Achilles, or to remove even some of the bone splinters. When the fragments have been brought well together, the injured foot should be dressed in a plaster-of-Paris bandage. Both the astragalus and the os calcis may be the subject of com- SPECIAL FRACTURES AND THEIR TP.EATMENT 917 pound fracture, in which case the damuK(Hl bones should be carefully cleansed and treated on the lines already laitl down in our discussion of compound fractures. The other smaller bones of the tarsus occasionally are crushed by direct violence. One ascertains the exact nature of their fracture through .r-ray investigation. Treatment is by rest and an ice-bag until the swelling has subsided, after which the whole foot should be put up in a plaster bandage. Fracture of the metatarsal bones is freciuent, and is due nearly al- wavs to direct violence. The first and fifth metatarsals are the bones coEQmonly broken, and the symptoms are swelling, crepitus, pain, abnormal mobility, and inability to stand on the foot. There is never great displacement, but an approximation of the fragments is neces- sary in order that the patient may be able to walk freely and_ easily after union has taken place. In the case of great displacement it may be necessary to employ temporary traction by special wooden sphnts, but ordinarily a plaster splint embracing the whole foot will suffice. These plaster' splints for fractures of the bones of the foot should always extend from the tips of the toes to above the swell of the calf. Fracture cf the phalanges of the foot is a rather rare accident. I have known cases in which the patient fractured a phalanx of the toe by stubbing the toe while walking barefoot. The displacement in these cases is slight and union is fairly prompt. Generally, a simple wooden plantar splint, properly padded and held in place with adhesive straps, is sufficient. The plantar splint which covers the entn-e sole of the "foot is the most comfortable. Sometimes it is well to immobilize the ankle-joint also in plaster. The patient should usually be kept quiet with the foot elevated until fair union has taken place. Bones of the Face Fractures of the bones of the face are interesting and extremely important, because upon the integrity of the facial bones depends the expression of the countenance and the familiar alinement of the features. The bones of the face are not long bones; their structure is irregular, while their outlines are various; moreover, they are mostly so placed as to permit of no proper splinting or immobilization, so that often it is necessary for the surgeon to contrive and adopt special maneuvers for the treatment of special fractures. The nasal bones are subject to fracture, while their damage may cause a marked deformity. Moreover, they are functionally con- cerned with breathing, so that their displacement may seriously inter- fere with the comfort of life. The nasal bones are usually fractured near their lower edge,_ and the fracture is compound, either Wo the nose or through the skin, while at the same time the cartilage of the septum is generally damaged. The upper lateral cartilages also may be torn from their attachments to the nasal bones, when there results a deformity which simulates fracture of those bones. 918 MINOlt SIRGEHY — DISEASES OF STRrCTlHE Fracture of the nose is not painful after the initial injury, but there is nearly always marked swelling and crepitus with the defonnity. Before undertaking the ti^eaiment of a nasal injury the sui'geon should examine carefully, with the aid of a head-mirror, the interior of the nostrils, and should correct any obvious displacement of the septum. Cocain anesthesia or general anesthesia may be necessary to accomplish this result, for the manipulation is painful. Then the surgeon should replace the fractured bone if there be a fracture, using within the nose a proper elevator. Roe's elevator is a useful instru- ment. The surgeon must then endeavor to hold the replaced bones in position. He may do this fairly well by packing the nostrils with gauze, if the fracture be high ; while if there is a low deviation, he may well use the Asch tube. In the case of a crushed nose he may model or reconstruct the nose over the Asch tube, one tube being placed in Fig. 622. — Fracture of nasal bones. Elevation of depres.sed bone by instru- ment introduced into the nostril (Scud- der). Fig. 62.3. — Cobb's splint applied to a case of fracture of the nose. Tlie head-band is .so adaj)ted to the shape of the liead that it remains fixed and of- fers a point of counterpressure (Scud- der) each nostril to preserve its contour and lumen. In those rather fre- quent cases which do not show deformity one need use no splint. Always when the mucous membrane of the nose is damaged, with a coincident compound fracture, the nares must be kept scrupulously clean with gentle douching, for which there is nothing better than a 50 per cent, alkalol wa.sh, or Seller's solution. Various external splints have been devised. I reproduce Cobb's splint and Coolidge's splmt, either of which is effective, though the Coolidge splint is much the cheaper. Make no promise as to the resulting deformity, for until the initial swelling has subsided and union is complete, no man may say whether a deformity will be permanent or not. In case of a slight depression SPECIAL FRACTURES AND THEIR TREATMENT 919 or deviation following healing, the .surgeon may remedy the defect bv the judicious subcutaneous injection of paraffin. ' Fracture of the malar bone generally results m a deformity of the face in a depression, which may or may not be noticeable to the patient's friends, though the man himself is sure to com- plain of the slightest imperfection. Indeed, it is not easy always to make out a fracture of the malar bone. The best method of examina- tion is to stand behind the patient, and with the finger and thumb of either hand to seize both malars, when a deviation of the affected side will generally be apparent. Fracture of the body of the bone Fi- 624.-Coolidge's nasal spUnt: a, Forehead plate; b, pad; c, screw controlUng position of pad; d, head-strap (Scudder). is not common, but fracture of one of its processes is seen not infre- quently. Often the bone appears depressed as a whole, or sometimes tilted inward toward the zygomatic fossa. The deformity is a depres- sion outside of and beneath the eye. There is often a stiffness, or even immobility of the lower jaw dependent either upon hemorrhage into the soft parts or upon bone pressure. At the same time the coronoid process of the mandible may be fractured and a subconjunctival hemor- rhage may appear in the orbit of the affected side. We treat fracture of the malar bone variously-either by manipu- lations or by seizing through the skin with bullet forceps {h. A ■Codman) and elevating the fragments of bone, always with the patient 920 MINOR SURGERY — DISEASES OF STRUCTURE anesthetized. Sometimes the depressed fragment may be elevated with a bkmt instrument introduced under the mahir bone from inside the cheek without opening the mucosa; or we may succeed by making a small incision in the mucous membrane, and thus approaching the seat of damage; or by opening the antrum in the canine fossa and intro- ducing an elevator which shall press up the fractured bone from within. Never undertake an exteinal incision if it can be avoided, for an external incision may prove of little value for the elevation of the bone, while it will be certain to leave a noticeable scar. Fracture of the upper jaw is rather more common than fracture of the malar, for the upper jaw is a more delicately constructed bone than is the malar. A jaw fracture is usually caused by a direct blow Fig. 625. — Four-tailed bandage for fracture of tlie lower jaw. upon the cheek bone, resulting in the crushing in of the external wall of the antrum of Highmore. Lothrop ^ has recently published an interesting and valuable essa}^ on this subject. After discussing the nature and anatomy of upper jaw fractures, he describes three methods of operative treatment, pointing out truly that operative treatment is the only satisfactory mode of treatment: First, operation by incision over the malar — a method to be discarded; second, the introduction of blunt instruments pushed up through the mouth — less objectionable than the first method, but generally ineffective and inadvisable. Third, Lothrop's own method, which I believe, from my personal experience, to be far the most valuable. This method consists in elevating the ^ Howard A. Lothrop, Fractures of the Superior Maxilla: A Method for the Treatment of Such Fractures, Boston Med. and Surg. Jour., January 4, 1906. SPECIAL FRACTURES AND THEIR TREATMENT 921 malar, together with the various fragments of the maxilla, working through a sn.iall opening into the antrum through the canine fossa. The operator makes a short horizontal incision along the junction of Fig. 626. — Hard-rubber splint, with arms and posterior strap (Scudder). the mucous membrane of the alveolus and cheek; he feels the line of fracture often, after having cut clown upon the bone. He then pushes a director through the opening into the antrum — an easy procedure. Fig. 627. -Hard-rubber splint, with arms and (Moriarty ) . applied. Similar to Fig. 626 He enlarges this opening sufficiently to pass into the antrum a steel sound (No. 24 French). With this instrument, and by a little forceful manipulation, the operator may press the fragments of bone up into their position and can hold them there by packing firmly the antrum with 922 MINOR SURGERY— DISEASES OF STRUCTURE gauze. The guuze should be left in place for four or five days, when it is withdrawn, the bone cavity carefully syringed out, and with proper aseptic precautions allowed to heal. 1 have seldom been obliged to keep these patients more than a week in the hospital. Fractures of the lower jaw can nearly always be determined by palpation, for the lower jaw is superficial, with the exception of a small portion of the ramus. Fractures of the ramus are rather rare, and fractures of the condyloid and coronoid processes are extremely rare. One sees that most fractures of the lower jaw must necessarily tear the mucous membrane of the mouth and must therefore be classed as compound fractures. The result is that these fractures are more serious, more dangerous, and more difficult of treatment than would at Fig. 628. — Lateral view of the Matas splint in situ, as shown on aduh skull (Scudder). first appear. The secretions of the mouth enter into the wound; sepsis results, with consec^uent necrosis and possible abscess formation, so that in the treatment of these injuries the surgeon must employ constant and scrupulous cleansing — mouth-washes, douches, and aseptic irriga- tions. The treatment of fracture of the jaw : Anesthetize — for the procedures are painful, not only the cleansing for the prevention of serious infec- tion, but, what is of almost equal importance, the manipulations for the preservation of the alinement of the teeth. We attain this proper alinement by a complete reduction of the bone fragments, if necessary-, by removing loose and obstructing teeth which may interfere with such reduction. SPECIAL FRACTURES AND THEIR TREATMENT 923 As for the common fnu-ture, that of the body of the bone, the frag- ments may as well be retained primarily by the old-fashioned four- tailed bandage until a permanent splint has been manufactured and applied. There are many varieties of permanent splints, and most of them, being made from molds of the jaw, fall naturally to the province of the dentist. Indeed, it is a common practice among surgeons in municipal hospitals to transfer to the hospital's dental department sim- ple cases of fractured jaw. I reproduce here illustrations of certain dental splints which are in ordinary use. At one time it was common practice to attempt immobilization of the fragments by wiring to- gether the two teeth on either side of the fracture. This practice is Fig. 629. — Compound fracture of lower jaw, caused by fist blow. Line of fracture oblique, bisecting lower jaw at angle and terminating above beliind last molar tooth. Great displacement and mobility of fragments. Reduction and apposition only obtained by splint. Barton bandage used to immobilize jaws with the spUnt. Splint worn eighteen days and followed by excellent results (Matas). ineffective, since such wiring loosens or pulls out of place the teeth so treated. There is a satisfactory method of wiring, more or less in vogue, however. This consists merely of fastening together, as it were, in a wire splint a large number of teeth on either side of the frac- ture, weaving a pliable silver wire in and out among them. For prac- tical purposes I have found this method serviceable. It is cleanly, it allows of ready access to the damaged parts, and it is not especially disagreeable to the patient, since it does awa}' with the cumbersome splints and harness which are frequently employed in hospital practice. Fractures of the ramus of the lower jaw are much more difficult to hold in place than are fractures of the body of the jaw. These frac- 924 MINOR SURGERY — DISEASP^S OF STRUCTURE tures of the ramus may be fairly well immobilized by a carefully applied four-tailed bandage, or, better still, is the molded leather splint of Mori- arty, or the ingenious but somewhat cumbersome splint of Matas. We have now considered the common and important fractures of the bones throughout the body. It is not possible in this writing to deal adequately with the numerous and distressing complications of frac- tures. One remembers also that many serious wounds of the soft parts are associated with fractures, and that the treatment of such fractures is a subordinate part of the care of the patient. Theie are, further, certain special types of fractures due to special forms of injury, man}^ of the most important of which are gun-shot fractures. Gunshot fractures are necessarily compound fractures, and the accident or damage to the bone is in proportion to the velocity of the projectile and the character of the bullet. The old-fashioned leaden bullet, of low velocity, gives often an ugly wound with an extensive splintering of the bone; while the modern high velocity conic bullet may do little more than pierce the bone and cause a slight splintering. X-va.y plates are needed in order to determine the exact nature of these various fractures; and the treatment of such fractures must be decided on general surgical principles. In broad terms, one may sa}' that a bone extensively splintered must be cut down upon and trimmed, while a bone merely pierced will probably heal without any great disturbance. It is rarely necessary to search for a bullet embedded in the tissues, unless the bullet is obvioush' a source of present irritation. A bullet, like any other foreign body, may remain indefinitely in a patient without creating noticeable damage. Pathologic Fractures Pathologic fractures, by which we mean .fractures resulting from new-growths, from infections, and from bones rendered brittle by dis- ease, occasionally are seen. Such fractures call for no special discus- sion in this place. It is obvious that fractures due to malignant disease are subordinate to the primary disease which must be the object of the surgeon's care; while fractures due to such non-malignant processes as rickets, etc., must be treated on ordinary principles, and the surgeon must make every endeavor to rectify the underlying ailment which led to the fracture. Dislocations Stimson gives the following excellent and comprehensive defini- tion of a dislocation: ''A dislocation is a permanent, abnormal, total or partial displacement from each other of the articular portions of the bones entering into the formation of a joint." A dislocation may be partial or complete. When it is partial or incomplete, it is frequently called a subluxation. Writers tell of predisposing and immediate causes of dislocations. These refinements need not concern us especially, for the fact is that DISLOCATIONS 925 the ordinan^ dislocations which are presented to the surgeon for treat- ment are dislocations of normal joints which have been torn asunder by extreme and external violence. Rarely the patient's own muscular action may cause a dislocation, as, for example, a dislocation of the lower jaw through excessive yawning; or the habitual and recurring dislocation of the shoulder-joint, produced by muscles acting upon a joint constructed with extremely relaxed ligaments. A dislocation long unrecognized and unreduced results m firm adhesions about the parts, rendering their subsequent reduction impos- sible without an open operation. These old dislocations, like old unrecognized fractures, are frequent subjects for law-suits. Perhaps the most common of the old unreduced dislocations is that of the shoulder-joint. One would suppose that a dislocation of the shoulder- joint should be easy of recognition. On the contraiy, in obese persons with heavy shoulders and flabby muscles, especially if they be short, stout women, the deformity of a dislocation of the shoulder-jomt is by no means obvious; the palpation of the region is difficult, and without an a--ray or bimanual manipulation the correct diagnosis frequently is not made. . 7 • i / That we may distinguish clinically between dislocations and Jrac- tures we must recognize certain striking points of difference. While there is pain in both conditions, the deformity of a dislocation is more marked than is the deformity of a fracture, and the loss of power after a dislocation is less considerable than after a fracture; but the most striking distinction is this— a fracture results in abnormal mobility, while a dislocation results in diminished mobility, or m a fixing of the bones in their new position. The course and outlook of a dislocation are shorter and more favor- able than is the case with a fracture. We can compare best the con- trasted features of the two injuries by considenng special regions; for example, a dislocation of the elbow-joint should incapacitate the patient for not more than two or three weeks, and the use of the joint should be completely recovered; while o. fracture into the elbow-jomt means many months of treatment, often resulting in a permanent impairment of function. Again, the dislocation of one of the phalanges imphes a disablement of not more than a week or two, with perfect restoration of motion; while a fracture of one of the phalanges is followed by disablement for from four to six weeks, with occasionally permanent limitation of motion and power. The treatment of dislocations is interesting and, m general terms, is active. The sooner a dislocation is discovered, the more easily may it be reduced. The original force causing the injury and the force neces- sarily apphed to correct it imply a great deal of traumatism to the joint, as well as a certain amount of tearing of the capsule. Often this trau- matism results in irritation of the joint serosa, m an outpouring of a considerable exudate, in effusion into the surrounding tissues even, and not infrequently in a straining, stretching, and tearing of the hgaments. For such reasons the surgeon must enjoin absolute rest for the joint 926 .MINOR SURGERY — DISEASES OF STRUCTURE for a day or two after the dislocation has been reduced. It is not neces- sary to put up the limb in an ininiobilizing dressing of plaster of Paris, but it is necessary to hold it snugly and comfortably in place with heavily padded bandages. During these first few days the effusion subsides ; the injection and hyperemia of the parts diminish ; the swelling disappears, and the region becomes noi'mal in appearance. In order to facilitate these natural processes we then prescribe massage for the joint and surrounding parts, and as the subsequent healing progresses, we stimulate and hasten it by continued massage. Old practitioners will recognize this treatment as quite different from the long-continued immobilization of former times. The present-day active measures return the joint to a normal and useful function with surprising rapidity; instead of waiting for many months, as used to be the case, we now expect a return of usefulness in a joint in a far shorter time. SPECIAL DISLOCATIONS Special dislocations offer special considerations to the student, and some of these considerations we have already taken up. In Chapter XXV, I have discussed briefly the question of dislocations of the vertebrse, Outer end of clavicle Fig. B.'^O. — Acromioclavicular dislocation. Dislocation of the outer end of left clavicle upward. Complete form. Disability of upper arm, certain movement.s painful. Treatment of tliis dislocation is often successful by pressure applied after reduction, as shown under Fracture of Clavicle. Open incision and suture are indi- cated if reduction is impossible and disability exists (Scudder). especially of the cervical vertebrae; and I have already in this present chapter referred to dislocations of the ribs, especially of the ribs upon the costal cartilages. These dislocations of the ribs are essentially similar to fractures of the ribs in their general effect upon the patient, and their treatment is similar to the treatment of fractured ribs. Dislocations of the Clavicle. — The clavicle may be dislocated at either its proximal or its distal end, and these dislocations may be found extremely difficult of reduction and fixation. In general terms, when the dislocation is at the yroximal end of the clavicle, we perceive SPECIAL DISLOCATIONS 927 that reduction is brought about by manipulations of the shoulder: by drawing the shoulder outward and backward, and by manipulating the dislocated bone, we can usually bring it back into place. The difficult task of retaining it in place will put the surgeon to his trumps. The shoulder must be bandaged and strapped into such a position as to favor present retention of the bone, and, if necessary, the patient must be kept quiet in bed for weeks even. So difficult and so disheartening are these cases often, however, and so persistently does the dislocation recur, that the surgeon frequently finds himself on the horns of a dilemma ; either he must submit to the forces of nature and allow the dislocation to remain unreduced, or he must transform the simple dislocation into an open one and retain the bone in place by suturing. I have found this last measure to be satisfactory. Dislocations of the clavicle at its distal end are extremely difficult of treatment also. It is a simple matter to reduce them, but their retention again is a problem. We reduce them by manipulating the shoulder. We retain them theoretically by such strapping as I have illustrated in the sketch. As a matter of practice, how- ever, we find that the most efficient method of holding these dislocations in place is by wiring, provided the patient is not willing to submit to the slight deformity of a permanent dis- location and the trivial loss of func- tion which this entails. Dislocation of the shoulder is one of the commonest of dislocations. The head of the humerus nearly always leaves the joint through the lower portion of the capsule, and goes to rest either beneath the glenoid cavity (subglenoid dislocation) or beneath the coracoid process (subcoracoid dis- location). There is also a subspinous or backward dislocation— a condition of the greatest rarity. For the purposes of treatment it matters Httle whether the dislocation be subglenoid or subcoracoid. Either one of the forward dislocations gives rise to a characteristic and definite picture and chain of symptoms: The patient sits bent forward and supports in his hand the elbow of his injured arm; the normal outline of his shoulder is changed; the deltoid is flat instead of rounded ; the elbow protrudes from the side and is fixed in that position ; the head of the bone may be palpated bimanually in the axilla. The surgeon should confirm these observations by the x-ray, through which Fie. 631.- -Dressing for dislocated clavicle. 928 MINOR SURGERY — DISEASES OF STRLCTUUE means also he must determine upon the i)rcscn('e or ub.sence of a coinci- \ the tendons held aside; the joint opened and disarticulated, and the involved bones and soft parts re- moved. Diseased foci in the tibia and fibula call for remcn-al of the ends of those bones. Diseased foci in the small bones of the tarsus call for the extirpation of the small bones involved. Excision of the ankle-joint frequently fails of its purpose; the disease may retui-n, while at the best we must look for healing with ankylosis and a deformed and crippled foot. Fig, 661 — Flint s excision — tibia cawed through; leg flexed; structures at knee above fallen into place a, Patella; h, patellar tendon; r, popliteal struc- tures; d, patellar tendon; e, skin-flap turned up; /, patellar tendon; g, tibia; /', tibia; /, tubercle of tibia (Flint, in Annals of Surgery i Fig, 662 — Flint's excision — leg hori- zontal; bursa turned down; saw in })lace. a, Retracted skin-fiap; 6, femur; c, (juad- riceps extensor; (/, l5ur.sa turned down; (', patella; /, saw cut in head of tibia; y, retractor (Flint, in Annals of Sur- gery) I shall not describe excisions of other joints, for the principles are already indicated, and are they not all described at length in countless volumes of operative surgery? Coxa Vara.* — Strangely enough, the term coxa vara does not appear m surgical literature until within recent years. Billings' Medical Dic- tionary^ of 1890 does not contain the words, though the condition has long been appreciated. Bent hip is a characteristic of rickets, and one finds it described in discussions of that disease. Bent hip may be due to an injury also — traumatic coxa vara. ' Coxa, hip; vara, bent THE JOINTS 971 Coxa vara is that condition of the femur in which the outer end of the neck of the bone is forced upward so that the trochanter rides above Nelaton's line, while the head of the femur remains in the acetabulum. The patient notices at first pain and a limp on the affected side, while the surgeon discovers a shortening of that leg unless the disease is bilateral; an abnormally high position of the trochanter; and inability to abduct the leg. The foot and leg are generally rotated outward, but all the motions are fairly free except abduction. If the disease be present in both hips, we discover a lordosis or forward curvature of the lumbar spine, to compensate for the tilting of the pelvis caused by the coxa vara. The x-ray should discover the exact position of the femora. Traumatic coxa vara may be found at any age, but especially in childhood. It results from an impacted fracture of the neck of the femur, due to a fall on the hip. The patient may suffer immediate disability, but with time and bony union a permanent deformity may result, so that the patient walks with a limp and suffers from pain in the joint. A child with this disablement may have night cries, and the clinical picture may resemble strongly that of the early stages of hip disease. We should call in the aid of the x-ray to settle every question of obscure hip lesion. We must distinguish coxa vara from a congenital hip dislocation also, as weU as from hip disease. Congenital coxa vara is a condition recognized within the last fifteen years only.^ This form of the disease appears to have no relation to rickets, but to be due to intra-uterine conditions through which the femur is adducted instead of being normally abducted. The trecdment of all forms of coxa vara is directed toward restoring the normal angle of the neck of the femur. If the patient is an infant or young child, and if the case is recent and traumatic, the patient should be anesthetized and the femur should be bent out to the proper angle; the leg should then be held in a plaster-of-Paris spica bandage for at least two months, in the new position. TMien the bandage has been removed, the convalescence should be stimulated by massage and by carefuUy protected use of the leg. There are many cases which do not permit of the forcible correction described above. In such cases we should employ such a protective splint as is used in cases of hip disease. The patient may then go about on crutches, with the strain of weight-bearing taken off the femur. In extreme cases of the disease the surgeon may perform a subtrochan- teric osteotomy by a linear incision throvigh the femur below the tro- chanter. He may then correct the improper rotation of the leg, and may hold the fragments in place with a plaster-of-Paris bandage until firm union has been restored. We see, therefore, that there is much to do for cases of coxa vara, and that a restoration of fair function maybe expected with confidence. 1 Kredel, in 1896, was the first observer to call special attention to the condition; and the literature of the subject is well summarized by Henrj' O. Feiss in the Jour. Amer. Med. Assoc, February 24, 1906. 972 MINOR SURGERY — DISEASES OF STRUCTURE There are many other rare affections of the joints at which avc must glance briefly. Coxa valga is a condition the reverse of coxa vara. In coxa vaiga the angle of the neck of the femur is increased. The disease may be either unilateral or bilateral. It occurs as a congenital ailment; in infantile paralysis; after long disuse of the leg; after amputations; and in rickets and osteomalacia. The deforniity is characteiized by an outward rotation and abduction of the leg, with limitation of the opposite movements; flattening of the trochanter; lengthening of the leg; pain in the hip; and a limp in walking. The a:-ray establishes a diagnosis. So far as treatment has been successful, it has been by osteotomy of the neck of the femur, and restoring the normal angle by pushing up and nail- ing or wiring the shaft to the necrk at the normal angle. Charcot's disease is a chronic and destructive affection of the joints and is usually seen in adults. One or many joints may be involved, and the symptoms resemble those of arthritis defoi'mans — swelling, effusion, loss of function, variable pain, and disintegration of the joint, followed by laxity and dislocation. Ankyloses and suppuration are rare; and although the disease is progressive, as a rule, it may cease spontaneously. The disease is extremely difficult of diagnosis unless the surgeon recognizes the invariable underlying and coexisting organic nervous affection, the discovery of wdiich is an aid in determining Char- cot's disease; w-hile the x-ray is of great value also, ^y^^vi. ■ , Treatment influences but little the progress of the Ailment; never- theless, we may look for some improvement by fixation of the joint and by protecting it with proper splints from damage. Resection of the joint is of little or no value, and amputation may be followed by a failure of Avound healing. Spondylitis deformans, a chronic and progressive stiffening of the spine accompanied by pain, comes within the province of the ortho- pedic surgeon, and the student should consult monographs on ortho- pedic surgery for Ji satisfactory study of this disease. Neuromimesis of the joints, hysteric joints, have interested surgeons for many years, and Sir Benjamin Brodie in the second quarter of the last century wrote the first satisfactory and convincing papers on the subject. In spite of the name w^e are coming to believe that many joints which seem to cause great pain "without a deformity or organic Q_^ lesion may not always be assigned to the hysteric class, since we may at times discover in these joints slight grades of arthritis deformans. Young women are the common sufferers from neuromimesis. There is often a story of injury; sometimes there are medicolegal complica- tions, and then a long history of pain and debility, with little or no apparent anatomic cause. Every experienced surgeon is familiar with these cases, and recognizes in them either malingery or a highly emo- tional temperament. Moreover, one should look in the patient's eyes for errors in refraction, and should investigate the (ondition of her pelvic organs. A careful neurologic study, based on the temperament of the patient and the history of the case, is necessary to detei'mine THE JOINTS 973 positively the presence of a hysteric joint; or it may be of a neurasthenic spine. It is needless here to discuss in detail the complex and extensive subject of treatment for hysteric joints. Treatment largely is general and moral — the building up of health, the improvement of the appetite, the regulation of functions, and the bringing of the patient to a realiza- tion of her true condition. In addition we prescribe such common- place factors in right living as an open-air life; cold bathing; exercise; regular meals, and abundance of sleep. Massage is often of great benefit, and the search for and pursuance of a congenial and useful occupation. CHAPTER XXXI AMPUTATIONS I\ the old surgeries the subject of amputations was probably the most important subject which writers had to discuss, for in the old days before asepsis surgery was destructive, mainly. To-day it is con- structive. Twenty-five years ago the teacher of surgical anatomy exercised his students for weeks at amputations upon the cadaver. To- day few students learn how properly to perfoim an amputation. In the old days he was the most skilful surgeon who cut off a limb with the greatest despatch consistent with preserving tissue enough to form a stump; and that despatch was a tradition inherited from the time before anesthetics were known. To-day, the careful surgeon amputates painstakingly and cautiously. Indeed, the most important purpose in an amputation to-day, aside from the purpose of a thorough removal of diseased tissue, is to provide the patient with a painless, serviceable, and sightly (sic !) stump. In these days amputations are relatively infrequent, because asepsis makes possible the saving of limbs which would have been sacrificed in old times. So latel}' as the American Civil War nearly all compound fractures were amputated. To-day we amputate in traumatic cases only when it is reasonably obvious that the soft parts of the limb have been damaged beyond salvation. Who may say what extent of tissue destruction shall render impossible the saving of a limb? The answer to this question depends upon a variety of factors. A robust young man with sound heart and kidneys, without taint of syphilis, tubercu- losis, or diabetes, may suffer a crushing injury, of extreme severity to his leg, yet the conservative surgeon may save ff)r him a useful member. On the other hand, the very young or the old, the alcoholic, the diabetic, the syphilitic, the victim of arteriosclerosis, after his accident may retain little power of recuperation for the mending of a shattered limb, so that an amputation is our feeble and only resort in his case. Such considerations are general considerations. Then there are considerations of special or local significance. The possil)ility of saving a damaged member is dependent largely on the amount of skin left uncrushed. An extensive area of sound and viable skin is more necessary for the preservation of a crushed limb than is sound bone or sound muscle; and the surgeon must assure himself that the circula- tion remains good in that part of the limb beyond the seat of damage also. A just estimate of all these factors will come from practice and experience only. 974 AMPUTATIONS 975 We operate "in continuity" when we cut through the bone in an amputation. We operate "in contiguity," or by disarticulation, when Ave remove the limb through a joint. We speak of amputations as "immediate," as "primary," and as "secondary." Immediate amputations are those which ai-e done at once, while the patient is still in shock, usually in from one to six hours after the injury. Primary amputations are done after the patient has reacted from shock, but before an infection has become manifest — usually within twenty-four hours after the injury. Secondary amputa- tions are done at any later period, and frequently after the establish- ment of an infection. The reasons for amputations are commonly three: (1) A serious crushing injury; (2) a destructive tissue disease (i. e., tumor; tuber- culosis) ; (3) a deformity or mutilation which the amputation may remove or correct. I have already discussed in general terms the traumatic class of cases. The principal diseases for which we amputate are destructive osteo- myelitis; extensive chronic ulcers of the soft parts; tuberculosis or advanced sepsis; the gangrene due to vascular or diabetic conditions; and tumors, usually of the malignant type. The victim also of a hope- lessly deformed and useless hand or foot may call for its amputation. One sees from this description that w^e may properly employ two other terms designating the urgency of an amputation: amputations of necessity, and amputations of expediency. Furthermore, according as amputations are those of necessity or expediency, so the technical nature of the amputation may be varied. There are the typical or classic methods which we employ when we can operate at leisure and follow the best and most satisfactory procedures; and, on the other hand, in an amputation of necessity we may be obliged to perform an atypical operation, cutting through where we must, and saving what we can, in order to secure a useful stump. Every experienced surgeon recognizes a further and marked pecu- liarity of the necessary amputation as contrasted with the expedienc}' amputation. The necessary amputation is done frequently upon a robust person, active and well up to the time of receiving his injury. His circulation is vigorous, and his reflexes acute. As a result, the ampu- tation itself, in addition to the shock of the accident, is a serious affair for him. Such a patient is liable to become extremely prostrated; to suffer intensely from shock; to recuperate slowly; and to experience a tedious wound healing. On the other hand, in the case of an expe- diency amputation, one observes frequently that the invalid, the victim of localized tuberculosis or malignant disease, experiences little shock from the operation. The removal of the diseased member seems to act almost as a stimulant. He rebounds at once from the primary shock of the amputation ; his general condition improves promptly ; and his wound heals readily and kindly, so that one may expect him to be in better general condition in a few days than he was before the operation. Regarding the technic of major amputations, let us consider three 976 MINOR SURGERY — DISEASES OF STRUCTURE important issues : the questions of shock and its control ; of hemorrhage and its control; and of the molding of the stump. The shock to ^vhich I refer is not that shock which resulted from the injury and existed before the patient was brought to us for opera- tion. That foim of shock I have already considered in Chapter XXVII of this book. Suffice it to remind the reader here that opium and the transfusion of blood are our most valuable remedies for that shock. The shock which occurs during the amputation, however, whether the amputation be one of necessity or expediency, is an additional shock. Though it is often inevitable, it is shock created by the procedure of the surgeon himself. For this reason one may call it induced shock, and may in a measure take means both before and during the operation to prevent it. This induced shock, anesthesia shock, operation shock, or whatever we may choose to call it, is primaiy shock, always in the case of amputa- tions of expediency (for tumors, deformities, etc.) ; but in the case of all amputations the surgeon must anticipate a certain amount of shock. We prepare for the contingency of shock by giving morphin and atropin (morphin sulphate, gr. l-{ ; atropin sulphate, gr. Tffij-eV) • We employ an anesthetic with discretion. In the case of minor amputations and sometimes in the case of major amputations even we may make use of local anesthesia. In certain selected cases, especiall}' when the patient is old and a sufferer from arteriosclerosis or renal disease, it may be well to use for anesthesia, tropococain, stovain, and strychnin b}' lumbar puncture. As a rule, however, we must employ a general anesthetic, and of the general anesthetics, we may rely upon nitrous oxid and oxygen, or ether — alone or combined. The administration of the anes- thetic should always, when possible, be confided to a skilled anesthetist, who should use the least possible amount of the drug. Further ex- pedients for eliminating shock are the placing of the patient upon a hot- water mattress during the operation, and the cocainizing of the large nerve-trunks before cutting them. This last maneuver (nerve cocain- ization) was first advocated by Crile some ten years ago, and has met with general approval. Expose the nerve and introduce within its sheath by a hypodermic needle 4 to 6 minims of a 4 per cent, cocain solution. Intimately associated with the question of shock is that of the control of hemorrhage — of hemorrhage which leads so directly to an increase, and a prolongation, of the shock. We control hemorrhage by producing a general ischemia of the limb to be operated upon, and by checking promptly the bleeding vessels in the wound itself. For the general ischemia we render the limb as bloodless as possible by elevating it for a few moments before operating, and by applying a tourniquet. Some operators still employ the Martin i-ubber bandage to squeeze the blood out of the limb, supplemented by the rubber tourniquet, after the method of Esmarch. I believe that, as a rule, however, this use of the Martin bandage should be discountenanced ; for in the case of a crushed limb, the bandage may give rise to embolism; while in the case of an AMPUTATIOXS 977 infected limb, or a limb the site of malignant disease, it is possible by the rubber bandage to force the products of disease into the circulation. Elevate the limb, therefore, and apply a tourniquet. I frequently employ the pneumatic suit also, as 1 have described its use in Chapter XX\'I1. We must observe a further precaution in the use of the famil- iar rubber tourniquet. If we draw it too tight or leave it in place too long, it may so press upon the underlying nerves as to cause their degeneration, with a subsequent paralysis. This rarel}- happens in case the tourniquet be applied to the thigh, but it has happened fre- quently after the application of a tourniquet to the arm. ^Yhen the Fig. 663. — Esmarch's elastic bandage and tourniquet tEsmarch'. arm is to be constricted, therefore, a few folds of towel should be laid beneath the tourniquet, and the tourniquet itself should be ribbon- shaped, and not made of the usual elastic tubing. The molding or shaping of the stump has become a matter of extreme interest in recent years, and we have come to see that the rapid, old- fashioned circular amputations often leave the patient with a stump poorly adapted for the wearing of an artificial limb. The treatment of the nerve-ends so as to avoid subsequent painful neuromata is another important desideratum. The old-fashioned circular amputation was Fig. 664. — Circular flap. made by turning back a cuff of skin, by cutting squarely through the limb at a level slightly higher than the cuff level, and completing the stump by drawing down and stitching the cuff immediately below the raw surface. This method of amputating is rapid, and gives us a symmetric and seemly stump. Unfortunately, however, it leaves the end of the stump in a condition easih' subject to injur}-; while on ac- count of its stiaicture this stump may become extremely painful. Some six years ago F. T. Murphy^ made an exliaustive study of a large num- ber of the end-results of amputations in the Massachusetts General 1 F. T. Murphy; A Study of Amputations of tlie Lower Extremity, Boston Med, and Surg. Jour., July 14, 1904. 62 978 MINOR SURGERY — DISEASES OF STRUCTURE Hospital clinic. His conclusions are valuable and are worth quoting here in full : ''Anterior and posterior muscle flaps, when obtainable, are to be preferred to the circular cuff of skin. " The fibula should be cut off at a higher level than the tibia in leg amputations, and care should be taken to bevel off bony prominences, such as the sharp anterior tibial edge. "Suture of the i^eriosteum and approximation of tlie mu.scles and fasciie are desirable. " Drainage of the stump is advised, unless the dead space is obliter- ated by means of buried sutures. " Partial amputations of the foot or amputations at the ankle-joint, except under unusual conditions, are not as satisfactory as those above the ankle-joint. " Tibial stumps between 6 and S inches long are the most serviceable. "Amputations through the knee-joint are inferior to those just above the condyles. "The longer the thigh stump the better, jjrovided the condyles have been removed. " In general, in tibial amputations down to 4 inches, and in thigh amputations down to 5 inches, sacrifice bone in order tc obtain good muscle-flaps." These observations of Mui'phy are sound, and while his studies embrace amputations of the lower extremity only, the general tenor of his conclusions is applicable to the upper extremity also. Let us note one exception, however, when we come to a consideration of arm amputations ; in arm amputations the circular cuff method is often valuable, while it rarely leads to a painful stump. In regard to the whole subject of stumps, let us note further that recent studies, notably those of Matas, von Mikulicz, Gritti, Bier, ■oy,, Hirsch, Berger, Kiister, and numerous other FV cc —P -'i' f writers, have dealt largely with the treat- Une oT sutures by the ob- ment of the bone itself. There is a general lique incision (Kocher). agreement, moreover, that muscle flaps — ^not mere skin-flaps — should be used; that the eventual line of skin suture should fall behind the limb, so that the bone stumi? may not press upon the soft cicatrix, and that the amputation should be made w'ith the same painstaking care as that employed in amputating a breast or a uterus. The old-time hurried slashing is improper. For such reasons many surgeons have abandoned entirely the ancient amputating knives, and cut ofi" the leg or the arm with an ordinary scalpel, much as they would cut off the breast. Neudorfer goes still further and abandons the saw itself. He cuts through the bone as a preliminary step in his operation, employing a sharp chisel or a Gigli saw (Fig. 666). AMPUTATIONS 979 The question of whether or not to cover the bone stump with peri- osteum is still (lebatetl. Many surgeons beheve that a proper periosteal covering promotes prompt bone-healing and a painless stump; while Fig. 666. — Neudorfer's method of amputation by primary division of the bone before sliaping the flaps (Matas). others, especially Hirsch, have contended that the periosteal covering is unnecessary, and Bunge maintains that the periosteum over the end of A Fig. 667— Bier's osteoplastic amputation of the leg: A, Showing manner of raising an osseoperiosteal flap from tibia; B, showing bone-flap brought oyer sawed ends of tibia and fibula, and its periosteal margins sutured to the margins of periosteum around tibia and fibula. The osseoperiosteal flap is here shown separated from its soft parts, to which it should be adherent. (Bickham, modified from Bier.) the bone is extremely sensitive. Bier, on the other hand, prefers an osteoplastic method — a covering of the bone-end with a transverse strip of new bone taken from higher up upon the shaft (Fig. 667). 980 MINOR surgp:ry — diseases of structure My own conviction and practice favor the use of periosteum to cover the bone-end. I have seen no special value in Bier's osteoplastic flap. I regtird the proper treatment of the muscles and the skin-flap, however, as of superlative importance. In our amputations we provitle consider- able muscle-flaps, which can be drawn over the bone-end, and we lace them together with buried absorbable stitches, so as to promote prompt union, a perfect hemostasis, and a reasonably shapel}- stump. In an amputation of the leg, the line of suture should fall jiosteiior to the bone- end, as Fig. 667 illustrates.^ Painful Stump. — Neuralgia of the stump may complicate the end- results after any form of flap- or stump-molding. Painful stump may be due obviously to a badly placed cicatiix, to a breaking down of the scar and ulceration, or to an unduly long bone; but all these calamities are avoidable and remediable by a secondary operation — shortening the stump. Thefe is one form of painful stump, however, the cause of which is much more deeply seated — a neuritis or growth of neuromata on the severed nerve-ends. These neuromata may be the despair of surgeon and patient alike. The pain is often excessive and extremely wearing, so that the patient's life becomes almost unbearable. The surgeon opens down upon the affected nerves, removes the neuromata, and resects the nerves, but often to no purpose; the pain returns; higher resections are made, and, finally, in desperation, the surgeon may remove the limb en- tirely or dissect the posterior nerve-roots of the cord. These are radical procedures, and often are a source of mortification to the surgeon. For the last four years I have been following the practice of joining to each other the severed nerve-ends in the stump itself — nerve anastomosis — ^ Theodor Kocher, in his Text-Book of Surgery, second English edition, p. 393, lays down the following interesting rules, which correspond with the conclusions we have drawn in the text: "An oblique incision (combined, if necessary, with a longitudinal one in the form of a racket or lanceolate incision) through skin and fascia. After retracting tlie elastic skin the muscles are divided obhquely down to the bone. The periosteum is also to be divided obhquely. The periosteum is then separated along with the superficial layer of the cortex of the bone, by means of a sharp raspatory or chisel, or, wlien possible, a flap of bone ha\'ing a movable periosteal hinge is made by means of tlie saw; lastly, if only a thin shell of the cortex lias been raised up along with the periosteum, the end of the bone is simply rounded off, wliile, if a distinct flap of bone (osteoplastic method) has been sawn up, the end of the bone must be sawn in a curved direction so as to fit it. "The periosteal or bony flap is sutured over the sawn surface of the bone to its periosteum. The stumps of the muscles or tendons are sutured to each other or to the surface of the bone at a distance from the sawn surface. Lastly, the skin and fascia are sutured. But in cases where a periosteal flap, or a flap of' bone and peri- osteum, cannot be obtained in a normal relation to the other soft parts, it is Ijetter to remove the periosteum entirely from the end of the stump, to scrape out the medullary cavity (accortling to Eiselberg and Bunge), and to round off tlie edges of the bone as dentists do. "In disarticulating, care for the shape of the end of tlie bone is unnecessary; the upper cartilaginous surfaces should be preserved, as they are insensitive and used to pressure. In addition, the points which we have emphasized in excisions are to be borne in mind, viz., to retain the attachments of the tendons, muscles, and liga- mentous capsule to the cortical layer of bone subjacent to them. In other words, the subcapsular method is to be added to wliat we have just described as the normal, so tliat tlie disarticulation is performed by what may be termed the periosteo-plastic- subcortical method." SPECIAL AMPUTATIONS 981 with the purpose of securing a continuous nei-ve channel, and leaving no nerve-ends whatever to serve as the seats of neuromata. In my list of 23 cases this maneuver has proved successful. I believe we are now warranted in employing it in all major amputations as a preventive of painful stump. SPECIAL AMPUTATIONS Amputation of the Toes. — As a rule, the surgeon should not ampu- tate through the phalanx of a toe, but should disarticulate at the meta- tarsophalangeal joint. The racket-shaped incision is the best incision, for by its use a plantar flap may be turned up over the wound, which is thus comfortably protected. After making the flap, the surgeon sharply flexes the toe at the selected point, and passes his knife rapidly Fig. 668. — Disarticulation of the great toe at the metatarso- phalangeal joint, and of the sec- ond toe along with its metacarpal bone: amputation through the third toe and through the fifth metatarsal bone (Kocher). Fig. 669. — Disar- ticulation of all the toes at the metatar- sophalangeal joints (Kocher) . Fig. 670. — Ampu- tation through the metatarsus (Kocher). through the joint cavity, remembering that he must enter the cavity at a point the bone's breadth beneath the knuckle. There are usually two terminal arteries to be tied. Be careful not to include nerve twigs in the ligatures. Do not sew up the flaps without providing for drainage between the sutures. Interrupted sutures are best. The inevitable slight leakage behind the flaps finds its way between the sutures, and if the wound has been made clean, healing is prompt. In the case of amputations of the great toe and of the little toe, make the cut somewhat toward the median line of the foot, so that 982 MINOR SIRGEHV-DISKASES OF STRUCTURE the line of suture, when {•()ni])leted, .shall not be subject to laterul pres- sure in boot-weai'inii'. Partial Amputations of the Foot. — Ani])utali()ii,s throujih por- tions of the foot have been modified l)y niany surgeons, and various names are given to the various foot amputations. We are coming to the conclusion that most of these amputations through the bones of the foot are objectionable, because the resulting stumps are weak, inconvenient, and painful. Total removal of the foot (at the point of election, 6 to 8 inches below the tibial tubercle) gives the patient a more useful limb. The amputations through the foot are sometimes useful, however, their designated names are classic, and the student should be familiar with their nature. Lisfrancs operation is a disarticulation of all the toes at the tarso- metatarsal joints — so obvious an operation that the .student of surgical history wonders why an)'' one man's name should have been associated with it. Lisfranc's operation is performed with a short dorsal and a long plantar flap — in other words, the .sole of the foot is dissected off and turned up over the stump. The surgeon seizes the toes with his left hand and begins his incision just behind the base of the fifth meta- tarsal bone. He carries the cut straight along the outer aspect of the foot for about an inch, and then rounds out to the dorsum, crossing the foot to its inner edge, and carries his knife back so as to complete the flap just above the cuneiform metatarsal articulation of the great toe, somewhat nearer the plantar than the dorsal aspect. He then forms his plantar flap, which should extend nearly to the tarsophalan- geal joint. The surgeon deepens his cuts, retracts his flaps, and then firmly extends the foot, when the disarticulation is an easy matter. He then removes the tourniquet and picks up the bleeding vessels. I believe it is wise to drain the wound with a rubber wick for twenty- four hours. The stump should be put up in a large elastic compression dres.sing reaching to the knee. The foot should be su])ported on a pillow, or slung in a hammock for at least a week, when healing should be sound enough to permit of the patient's beginning to move about on crutches. Hey's operation is similar to Lisfranc's, except that, in addition to the disarticulation of the metatarsal bones, the end of the internal cuneiform bone is sawed off, so as to provide a smooth and even bone stump. Chopart's operation is a disarticulation of the anterior part of the foot at the mediotarsal joint, that is to say, the astragaloscaphoid joint and the calcaneocuboid joint. The operation provides flaps similar to the Lisfranc flaps, except that they are made somewhat longer and are started opposite the calcaneocuboid joint. Syme's operation — disarticulation of the foot at the ankle-joint. Syme's operation pre.serves the plantar surface and the soft parts of the tip of the heel, which is made to cover the lower ends of the tibia and fibula, whose malleoli are removed. The surgeon makes his incision directly down to the bone from the tip of one malleolus across the sole SPECIAL AMPUTATIONS 983 and up to the other. lie then forces the foot into extreme phintar ilexion, and carries a second incision directly across the dorsum, thus joining the two entls of the first incision. He then opens the ankle- joint in front; divides the lateral ligaments and disarticulates the astragalus forward. Next he separates the soft parts of the heel from the OS calcis, which he removes. He has now left the articulating ends of the tibia and fibula. He saws off the malleoli and turns the heel-flap up over the stump. Pirogoff's operation — disarticulation of the foot at the ankle-joint, with removal of the malleoli, the articular surface of the tibia, and the anterior part of the os calcis. As Kocher remarks, Pirogoff's operation Fig. 671 . — Plantar incisions : A, Lis- franc; B, Chopart; C, Pirogoff; D, Syme; E, Farabeuf's subastragaloid amputation; F, Farabeuf's amputation at the ankle (Dennis). Fig. 672. — Pirogoff's amputation: Appearance of the parts after removal of the malleoli (Erichsen). derives its importance from the fact that it was the first osteoplastic operation introduced. It dates from 1854. Pirogoff's operation resembles Syme's in many of its features. The Syme incision is employed, and all the bones of the foot are removed except the posterior portion of the os calcis. This slip of bone is shaped by the use of a small saw as indicated in the cut. It is well to begin Pirogoff's operation by a tenotomy of the tendo Achillis, thus allowing the heel-bone readily to be drawn up and implanted upon the stumps of the tibia and fibula. The Pirogoff stump is fairly useful, and is more satisfactory than that of Syme. Amputations of the Leg.— The subject of leg amputations has been one of no little controversy, the matters in dispute being particularly— 984 MINOR SUPGEHY— DISEASES OF STHUCTUKE (1) The best point at -which to amputate; and (2) the method of amputation. Surgeons are now agreed that amputations should be made as low as possible consistent with the production of a stump capable of bearing an artificial leg. So we have coined the term "point of election," by which we mean a point on the tibia about eight inches below the tibial tubercle. Amputations above this point are not of election, so that the nearer we come to the point of election, the more satisfactoiy will be our results. In the lower and middle thiids of the leg the bulk of the muscles is posterior; when we operate in this region, therefore, we find that a posterior flap gives the best covering for the stump. ^^ hen we operate in the upper third of the leg, where the bulk of the muscles is postero-external, we aim to secure a flap chiefly external. Whatever flap be made, we should cut the fibula Fig. 673. — Cross-section of lower third of the right leg (adapted from Bickham). slightly higher than the tibia, as the fibula in the stump is easily drawn out of position and exposed to pressure. In sawing through the bones of the leg we should be careful to bevel the anterior edge of the tibia before making the transverse cut. There is little difficulty usually in finding the arteries and controlling hemorrhage from a leg stump. The important arteries are the anterior tibial, the posterior tibial, and the perineal, whose positions are shown in the illustration taken from Bickham's Operative Surgery. We need not here consider the great variety of .special amputations which have been devised for special conditions, but we may suggest, by means of the illustrations in the text, the nature of the various incisions which we recommend. For amputations at the point of election, if we discard the old-time Sl'ECIAL AMPUTATIONS 985 cuff method, we shall do well to follow the line of Stephen Smith's operation, and tiu'n up a long posteiior flap, observing that the cut through the bones is made at the highest point attainable above the base of the flap. • In making these leg amputations the surgeon should have in mind and should follow a proper routine if he is to have his operation come off smoothly and easily. The patient should be drawn well over the end of the operating table; the sound leg should be tied down out of the way, and an assistant should hold the foot to be am- putated in a somew^hat elevated position in order that the surgeon may have every part of the leg circumference well within the sweep of his knife. He may make a large skin-and-muscle flap by transfixion and cutting outward with the long amputating knife; or he may dissect a skin-flap back carefully with a scalpel. After he has com- pleted his flaps, he may employ the old- time Catlin in order to clean away the inter- osseous tissue, or he may dissect this tissue away with a scalpel. My own preference is to use a small knife through most of the operation, for with the small knife one works more accurately and may quickly ex- pose the bone-ends, from which periosteum is to be stripped back before the bones are sawed. Having turned back the periosteum and the soft parts, and having sawed through the bones, the surgeon searches at once for the important arteries with their veins, and ties them all; he has the tourniquet re- moved; he picks up with catch forceps all the smaller bleeding points, and checks entirely all hemorrhage, tying the vessels with silk or plain catgut, according to his convictions regarding ligature material; he draws out the nerve-ends and stitches them accurately together end to end. He then completes the hemostasis, if that be needed, and molds the stump by careful suturing and lacing of the muscles across the bone-end. Finally, he brings the skin-flap accurately into place. Some redundancy of skin-flap is an advantage rather than the reverse. If the hemostasis be absolute, drainage wicks are unnecessary, but, as a rule, it is well to drain the stump for twenty-four hours at least. At the time of the operation the surgeon may deem all hemorrhage checked, but later, when the patient has been put to bed, when shock has subsided, and when the Fig. 674. — Amputation of leg: A, Modified circular; B, rectangular flaps; C, antero- posterior flaps, upper tliird. 986 MINOR SUHGEIIY — DISEASES OF STIUTTl-RE arterial circulation again has become vigorous, a secondary oozing into the stump is common. The leg should be tlressed in an abundant ab- sorbent dressing, reaching well above the knee, and the whole liiiih should be carefully immoljilizcd ui^on a comfortable s])lint. Many surgeons prefer the Teale metiiod of aminitation. The Teale method is that of providing a long anterior flap. The resulting stump is seemly and useful, while the operation is somewhat easier than that I have just described. Amputations through the middle of the calf are perfoi-med on much the same plan, for the arrangement of the parts does not differ materially from their arrangement in the lower third of the leg. When we come to amputations in the upper third of the leg, or im- mediately below the knee, we have to consider the possibility of adapt- ing the short stump to an artificial leg. Many surgeons believe that we should never make a tibial stump less than four inches long, but that the surgeon should perform his amputation by disarticulating the knee-joint, or by amputating above the femoral condyles. I have Fig. 67.5. — Teale 's amputation. fovmd, however, that a short tibial stump, which is often troublesome on account of the back pull of the hamstring muscles, can be made useful if we perform a tenotomy on the hamstrings. Many surgeons still amputate through the knee-joint. At the Massachusetts General Hospital we rarely ])erform this operation, as we are convinced that amputation above the condyles of the femur gives the patient a more useful stump. Should the surgeon think it wise, however, to perform knee-joint disarticulation, he may well follow the commonly adopted bilateral method of Stephen Smith. Begin the incision one inch below the tubercle of the tibia, and carry it downward and foi-ward around the side of the leg and so up into the popliteal space, making a lateral flap. Duplicate this flap on the other side. Separate the soft parts from the bone; divide the joint ligaments and remove the leg with the patella. Some observers maintain that this disarticulation causes less shock than does a regular amputation. Be that as it nux}', we secure a far better stump by supracondyloid amputation. SPECIAL AMPUTATIONS 9S; Supracondyloid Amputation.— Frohixhly the best method for this operation is that suggested by Stokes and Gritti, which consists of section of the femur above the condyles with an osteoplastic flap, formed by the split patella. The authors point out that by this means the. strong anterior weight-bearing patellar sui'face becomes the end of the stump. As we approach the hip-joint in our amputations, the danger of shock increases, coincident with a rise in the operative mortality. For such reasons surgeons should amputate the thigh with great care and forethought, using every means to minimize shock and hemor- i-l^j^ge— especially by elevation of the leg; by careful application of the tourniquet; by perfect hemostasis, and by nerve cocainization. I Ti£ 676-Wyeth's hip-joint amputation: Pins and rubber tube tourniquet in position. The Esmarch bandage has been removed (Wyeth). prefer long muscle-flaps when they are available, and a thorough lacing together of the flaps in completing the suturing of the stump. _ In mid-thigh amputations the surgeon has to find and secure especially the femoral and popliteal arteries, while he must take pams to_ treat the sciatic and anterior crural nerve-ends by a proper anastomosis. The hip-joint amputation has always been a matter of keen interest to surgeons since amputations at the hip-joint have been done, for the operation is a relatively modern one.^ The shock is often extreme, and the hemorrhage not always easy to control, while death from complications may follow unexpectedly. Not long ago I had 1 Walter Brashear, at Bardstown, Kentucky, in August, 1806, performed the first successful amputation at the hip-joint. 988 MINOR SURGEin' — DISEASES OF STIU'CTURE occasion to amputate at the hip-joint for Harconia of the thi., 906, 967, 968, 969, 970 Focal epilepsy, 661 Follicular cysts, 334 odontoma, 562 Foot, amjjutation of, 982 bones of, dislocation of, 940 phalanges of, 917 Foramen of AVinslow, 76 P'orearm, bones of, dislocation backward of jjoth, 881 fracture of, 884 Foreign body in bladder, 4 1 1 in bronchi, 479 in esophagus, 123 in intestines, 56 in larjmx, 579 in rectum, 92 in trachea, 579 in urethra, 451 Fossa, intersigmoid, 76 navicularis, 433, 435 retrocecal, 76 retroduodenal, 76 Fothergill, 267 Four-tailed bandage, 920 Fowler, George Ryerson, 40, 212, 232. 282, 365, 375, 429, 440, 494 Fowler, Russell S., 232 Fowler's operation, 493, 494 position, 55, 81, 231, 233, 783 Fracture, 849, 853 Bennett's, 894 closed, 729, 852 Colics', 886 compound, 736, 850, 858, 912 greenstick, 854 gunshot, 924 immobilization of, 730 open, 736, 852 treatment of, 851 pathologic, 854, 924 periosteal, 854 punctured, 622 simple, 729, 850, 854, 855 spiral, 854 of base, 622, 633 of carpus, 891 of clavicle, 863 old, 891 of coronoid process, 886 of elbow, 877 neglected, 883 of femur, 895 neck of, 896, 899 shaft of, 900 su]>racondyloid, 903 of fibula, Pott's, 913 of forearm, bones of, 884 of humerus, 868 anatomic neck of, 871 lower enil of, 879 surgical neck of, 872 of hyoid, 579 INDEX 1001 Fracture of jaw, lower, 922 UpjHT, !)2() of leg, 907 of patella, 904 of pelvis, 8()2 of plialanges, 895 of radius, liead and neck of, 886 neck of, 881 of ribs, 859 of scaphoid, 892 of sca])ula, 867 of skull, 620 of sternum, 861 of thigh in children, 903 of thyroid, 579 of vault, compound, 623 simple, 623 of vertebrae, 676 Fragilitas ossium, 952 Frame, Bradford, 903 Frank, Jacob, 163, 212 Frankel, 495 Frazier, Charles H., 613, 709 Frederick, Emperor, 584 Freudenberg, 420 Freyer, 423 Friedrich, 484 Fritsch, 635 Frost-bite, 815 Fuller, Eugene, 444 Fundus uteri, cancer of, 306 Fungus cerebri, 658, 659 Funke, John, 595 Galactocele, 531 Galen, 669, 772 Gall-bladder, enlarged, 172 Gall-stones, 169 Gamgee, Sampson, 724, 742, 853 dressing, 754 Ganglion, Gasserian, 699, 702 Cushing's operation upon, 703 tuberculous, 806 Gangrene, 22, 73 of lung, 485 Gangrenous appendicitis, 22 Garceau, Edgar, 3{57 Garrigue, 351 Gastrectasia, 128 Gastrectomy, 148 Gastric adhesions, 143 cancer, diagnosis of, 147 symptoms of, 147 cirrhosis, 144 dilatation, 61 erosions, 130 hemorrhage, 141 ptosis, 61 surgery, 127 tetany, 129, 144 ulcer, 128, 133 Gastroduodenostomy, Finney's, 136 Gastroenterostomy, 127, 134, 140, 142, 179 anterior, 134 Gastroenterostomy, posterior, 135 Gastrogastrostomy, 143 Gastroplasty, 132 Gastroptosis, 129, 144, 243 Gastrostomy, 64, 121, 126, 151, 152 feeding by, 153 preliminaiy, 119 Witzel's, 64 Gatch, 232 Gay, George W., 100, 473, 848 Gaylord, 847 General condition, 720 Genital herpes, 448 lesions of syphilis, 444 Genito-urinary organs, 358 Gerhardt, 73 Gerlach, valve of, 18, 20 Gersuny, 389 Gersuny's method, 814 Giant-cell sarcoma, 832 Gibbon, John H., 500 Gibson, C. L., 48, 75, 419 Gilliam, 282 Gimbemat's ligament, 213 Girard, 212 Glabella, 637, 665 Gland cancer 845 carotid, 595 Cowper's,"433 in neck, 589 lymph, 796 of Littre, 433 parotid, excision of, 575 salivary, 574 suprarenal, 382 tumors of, 386 swollen, 590 thyroid, 597 cancer of, 610 Glandules, parathyroid, 597, 608 Gleet, 441 treatment of, 442 Gl^nard, 60, 243, 244, 245 GMnard's disease, 60 Glioma, 654, 838 Gliosarcoma, 689 Glossitis, chronic, 570 Gluck, 162, 584 Gluteal hernia, 192 Goiter, 597, 602 aberrant, 611 causation of, 604 colloid, 609 cystic, 603, 606 diagnosis of, 604 diffuse, 602 exophthalmic, 597, 600 malignant, treatment of, 611 treatment of, 604 Goldspoon, 351 Goldthwait, J. E., 244, 812, 957 Gonococci of Neisser, 435 Gonorrhea, 269, 434 acute, treatment of, 436 chronic, 441 of rectum, 93 1002 INDEX Gonorrheal bubo, 439 conjunctivitis, 434 cystitis, 440 Goodcll-l'lUinger tUlators, 267 Gottschalk, 297 GouUl, A. II., 135, 136 Gouley, 391 Grafting, nerve, 711 Grafts, Wolff, 815 Graluun, Douglas, 763 Grunt, W. \V., 5.")2 Gnint's operation for cancer of lip, 551 Granulating wounds, 740 Granulations, exuberant, 741 Pacchionian, 643 Granuloma, infectious, 654 Graves, W. P., 279 Graves' disease, 600 psychic aspect of, 601 treatment of, 601 Grawitz, P., 382, 383 Greenough, R. B., 163, 231 Green-stick fracture, 854 Gritti, 978 Growths, benign, 845 malignant, 845 Grtmbaum, 638 Guaiac test, 132 Gunkel, 99 Gunshot fractures, 924 wounds of bladder, 410 "Gunstock elbow," 852 Guthrie, Charles C, 792 Hall, Basil, 191, 212 Halstead, A. E., 57 Halsted, William S., 212, 515, 608, 610, 780 Halsted's metallic bands, 786 operation, 210, 211 Hamilton, A. J. A., 427 Hand amputations, 991 Handley, W. S., 512 theory of, 842 Hanks' dilators, 267 Hare, 772 Harelip, 532, 534 double, 537 operation, a dressing after, 539 position for, 536 treatment of, 535 Harrington, F. B., 408 Harris, M. L., 164, 364, 429 Harte, R. H., 64, 67 Hartley, 705 Hartwell, John B., 107, 108 Harvard, 58, 129, 130 Hawkins, 30, 236 Head, 613 lesions, symptoms and diagnosis of or- ganic, 634 Headache, 641 Heart, 496 wounds of, 499 Heath, 200, 339 Ilcidenliain, 357 Ileinricius, 189 Heister, 670 Hclferich, 888, 934, 941 Ilelmholz, H. F., 617 Hematocele, 468 pelvic, 341, 344 Hematoma of ovary, 336 of scalp 615 Hematomyelia, 675, 676 Hematosalpinx, 320, 344 Hemorrhage, 976 cerebral, 629 extradural, 627 gastric, 141 intestinal, 65 intracranial, 627 of newborn, 629 subdural, 628 Hemorrhoids, 89, 99 external, 100, 102 internal, 100 mixed, 100 operation for, 101 Hemostatic bulb, 422 Hemothorax, 488, 495 Hepatic arteiy, aneurysm of, 167 Hepatoptosis, 165, 166, 243 Hernia, abdominal, 192 cerebri, 658, 659 congenital, 193, 215 diaphragmatic, 192, 220 direct, 201 duodenal, 221 epigastric, 192 femoral, 195, 213 treatment of, 214 gluteal, 192 incarcerated, 196 indirect, 201 inguinal, 192, 199 direct, 210 in women, 213 oblique, 206 in women, 195 internal, 76 irreducible, 196, 205. lumbar, 192 multiple, 194 obturator, 221 pelvic, 289 perineal, 289 radical cure of, 198 reducible, 195 retroperitoneal, 193, 221 sciatic, 192 scrotal, 192, 204 strangulated, 196, 197 treatment of, 198 umbilical, 215 of adults, 216 treatment of, 216 of infants, 216 ventral, 192, 219 Herniotomy, 199 Herpes, genital, 448 INDEX 1003 Hosselbach's triangle, 201 Hey, 418 Hey's operation, 982 Hill, L. L., 363, 499 Hip, dislocation of, 935 fracture of, ununited, 899 Hip-joint, am])utation, 987 excision of, 966 Hippocrates, 398, 488, 772 Hij){)ocratic facies, 50, 227 Hirsch, 978 Hirst, Barton Cooke, 331 , His, 613 Hitzig, 635 Hochenegg, 389 Hodgkins' disease, 799, 800 Hoffa, 939 Hoffmann, 444 Holm, 162, 242 Holmes, 784 Homans, John, 17 Hooper, F. W., 581 Horns, 448 cutaneous, 838, 839 Horse serum, 814 Horsley, Victor, 613, 658 Horsley's cyrtometer, 638 Hotchifiss, Lucius W., 39 Hough, 34 "Housemaid's knee," 809 Howell, 767 Humerus, fracture of, 868 lower end of, 879 neck of, anatomic, 871 surgical, 872 Hunter, John, 415, 434, 730, 772 operation of, 786 Hupp, 107 Hutchinson, Woods, 20 Hydatid cysts, 822 Hydatidiform mole, 318 Hyde, 392 Hydrocele, 470, 823 congenital, 473 of neck, 594 of round ligaments, 330 of tunica vaginalis, 471 treatment of, 472' Hydrocephalus, 644 Hydromyelia, 681 Hydronephrosis, 371, 374, 375 false, 374 intermittent, 374 Hydrops, 961 of appendix, 22 Hydrosalpinx, 320, 322 Hydroscope, 471 Hydrotherapy, 766 Hydrothorax, 488, 494 Hydroureter, 308 Hyoid bone, fracture of, 579 Hyperemia, passive, 963 Hyperemic treatment. Bier's, 795 Hypernephroma, 382, 383, 384 Hyperthyroidism, 600 Hypertrophy, diffuse mammary, 526, 527 Hypertrophy of prostate, 415 of rectal valves, 90 Hypodermoclysis, 770 Hypospadias, 459 balanitic, treatment of, 460 Stimson's operation for, 460 Hypothesis, Cohnhein's embryonal, 820 Hysterectomy, 292 abdominal, for cancer, 315 pan-, 297, 303 for cancer, 317 supravaginal, 297, 301 vaginal, 310 Hysteric joints, 872 Ichthyosis, 571 Icterus, 170, 172 Idiopathic dilatation of colon, 76 peritonitis, 225 Iliac artery, common, 780 external, 780 Ileocecal cancer, 80 tuberculosis, 69 Ileum, 21 valves of, 21 Ileus, dynamic, 48 gastromesenteric, 52 mechanical, 48 Imbecihty, 662 congenital, 662 Immobilization, 726 of fractures, 730 Imperforate anus, 90 rectum, 90 Incised wounds, 724 Incontinence of urine, 397 Indigo carmine, 363 Infarct, acute, unilateral, septic, 377 Infection, acute hematogenous, 377, 378 Infectious granuloma, 654 Infective bursitis, acute, 812 Inflammation about umbilicus, 254 of bile-passages, acute, 171 of esophagus, 127 of prostate, 412 of rectum, 92 gonorrheal, 93 of testicle, 468 of thyroid gland, 611 of tongue, 570 of uterus, 261 Inflammatory stricture, 455 Infusion, intravenous saline, 771 Ingrowing nail, 757 toe-nail, 758 Inguinal canal, 192 hernia, 192 Inhalation pneumonia, 584 Inion, 637, 665 Innominate artery, 777 aneurysm of, 785 Insanity, 662 Intercostal nerA^es, 716 neuralgia, 504 Intermaxillary bone, 537 1004 IXDKX Internal carotid arton'. 770 fistula, S2, 97 licniorrlioids, 100, 101 hernia, 7(5 Intersio;nK)id fossa, 76 Intestinal cancer, 77, 78 diajjnosis of, 79 incurable, 79 symptoms of, 78 treatment of, 79 hemorrhage, do lesions, symptoms of, 46 localization, 43, 44 obstruction, 47, 182 acute, 48 diagnosis of, 50 pathology of, 49 treatment of, 50 chronic, 53, 68 symptoms of, 53 treatment of, 54 perforation, 55, 56 traumatic, diagnosis of, 55 ptosis, 61 treatment of, 62 stenosis, 69 strangulation, 50, 51 Intestines, actinomycosis of, 69 foreign bodies in, 56 injuries to, 54 sarcoma of, 77 tuberculosis of, 67 tumors of, 76 benign, 77 Intracranial hemorrhage, 627 of newborn, 629 operations, technic of, 663 tumors, 654 Intramedullary tumors, 689 Intraspinal tumors, laminectomy for, 694 Intravenous saline infusion, 771 Intubation of larynx, 579, 581 O'Dwyer's, 580 Intussusception, 58, 73, 74 Invagination, 73, 74, 78 Involution, abnormal, 527 Ischemic atrophy, 801 Ischiorectal abscess, 95, 9G Israel, 372 Jackson, Henry, 156 Jackson, James M., 71 Jacksonian epilepsy, 655, 661 Jackson's (Jabez N.) operation for can- cer of breast, 520 Jacobson, 176 Jaundice, 177 Jaw, 558 ankylosis of, 560, 561 cancer of, 564 fibroma of, 561 lower, dislocation of, 940 excision of, 568 fracture of, 922 reconstruction of, 559 Jaw, lower, resection of, 564 sarcoma of, 563 tumors of, 5()1 upj)cr, fracture of, 920 resection of, 565 Jejunojejunostomy, 1 34 Jejunostomy, 121, 152 Je'pson, 189 Jewett, 262 Joerss, 514 Joint, ankle-, excision of, 969 hip-, excision of, 966 knee-, excision of, 967 wrist-, excision of, 965 "Joint-mouse," 958 Joints, 943, 955 contusions of, 955 excision of, 964 hysteric, 972 tuberculosis of, 960 wounds of, 734 Jones, Daniel Fiske, 409 Kader, 152 Kahler's disease, 651 Kammerer, Frecleriek, 215 Kausch, 78 Keen, W. W., 67, 163, 584, 595, 630, 644 Keetley, 368 Keith, George E., 848 Keith, Skene, 848 Kelly, Howard A., 40, 210, 211, 255, 259, 260, 273, 276, 282, 285, 294, 306, 307, 308, 316, 317, 322, 328, 329, 335, 355, 359, 362, 371, 719 Keloid, 816, 817 Keratosis, 570 Kidney, 358 carcinoma of, 385 decapsulation of, 386 floating, 247 treatment of, 248 horseshoe, 360 infection of one, acute hematogenous, 377 injuries of, 366 palpating, 361 ruptured, 366, 367 sarcoma of, 384 stone in, 369 surgical, 376, 377, 378 tuberculosis of, 380 tumors of, 381 wt)untls of, 368 Killian, 480 Kingscote, 212 Klebs, 125 Knee, dislocated, 939 Knipe, Norman, 331 Knott, Van Buren, 160, 161, 232 Koch, 591 Kocher, Albert, 598, 599, 601, 609 Kocher, Theodor, 86, 109, 110, 111, 150, 163, 176, 212, 215, 471, 572, 605, 624, 630, 700, 980 INDEX 1005 Kocher mptlind, 020 for artificial anus, S6 Konis;. 171, U(il2 Korto, 82 Kousnetzoff, 1G3 Kovnvor, 101 Kraske, 100, 110, 111, 212 Klaus, 120 Kreilel, 071 KrishalHT, ■')83 Kiunlein, R. N., 630, 638 Kurpjuweit, 404 Ku8tor, 212, 368, 429, 078 Kiistner, 355 Lacerated wounds, 732 Laceration, perineal, 345 Lacunse laterales, 643 Laminectomy, 601, 692, 694 Lancereaux, E., 786 Landau, 243 Langerhans, 471 Lannelongue, 159 Larrabee, R. C, 247 Larrey, Baron, 496, 631 Lar\-ngectomy, 584 Larynx, cancer of, 583 extirpation of, partial, 585 total, 584 foreign bodies in, 579 intubation of, 579, 580, 581 tumors of, 583 Lateral anastomosis, 68 perineal route, 400 Lauenstein's operation, 356, 991 LeConte, R. G., 233, 992 Le Dran, 733 Leg, amputation of, 983 circumcision of, 775 fracture of, 907 ulcer of, 742 varicose veins of, 774 Lejars, 581 Lembert, 42, 84, 123, 142 Lemonier, 534 Lenhartz, 495 Leptomeningitis, 647 suppurative, 648 treatment of, 649 Leukemia, myelogenous, 190 splenic, 191 Leukoplakia, 571, 845 Le"\verenz, 187 Lexer, 242 Leyden, 224 Lice, 504 Ligament, broad, cysts of, 330 dermoid, 331 tumors of, 330 varicocele of, 331 of Treitz, 135 . round, hydrocele of, 330 uterosacral, 270 Ligamentum patellse, 808 Ligation of arteries. 776 Lilicntlial, II., 41, 177 Lime-water enema, 93 Lingual artciy, 779 Liniiart, 545 Lip, cancer of, 548 upper, carbuncle of, 555 Lipoma, 826 arborescens, 826 diffuse, 827 Lisfranc's operation, 982 Lister, 17, 42 Litholapaxy, 400, 402 Litliotomy, perineal, 404 Lithotrite, 402 Lithotritv, 400 Little, 035 Liver, 155 abscess of, 156 approach to, transthoracic, 159 cirrhosis of, 163 Hanot's, 164 cysts of, 157 floating, 250 ptosis of, 62 resection of, 162 syphilitic, 160 tumors of, treatment of, 161 Lochet, 495 Locke, Edw-in A., 959 Lock-jaw, 560 Lodge, Henry Cabot, 581 Loeb, 847 Lothrop, Howard A., 105, 891, 920 Lovett, Robert, W., 957 Lower jaw, fracture of, 922 Lumbar hernia, 192 puncture, 648 Lund, F. B., 385, 944 Lvmg, 478 abscess of, 484 cancer of, 486 echinococcus of, 485 gangrene of, 485 injuries of, 486 sarcoma of, 486 Luys, 364 Lymph nodes, 792, 793 disease of, malignant, 800 of neck, 589 retroperitoneal, tuberculosis of, 239 tuberculous, 799 varices, 796 vessels, 793 Lymphadenitis, 798 chronic, 707 Lymphadenocele, 796 Lymphangiectasis, 796 Lymphangioma, 796, 837 Lymphangitis, 704 chronic, 706 Lymphatic connections of uterus, 257, 260 cysts, 594 system, 792 physiology of. 703 Lymphatics of stomach, 146 1006 INDKX Lynipliocystnma, 799 Lynipliosarcoiiui, 830 Mackenroth, 355 Macroglossia. 570 iMajiendic, 670 Majrnai, 212 Malar bone, 919 Malaria, 189 Malformation of umhilicvis ami urao 253 .Malgaifjne, 193, 536 Malignant degeneration of scars ulcers, 817 disease of lympli nodes, 800 growths, 845 tumors, 818 ]\Ialunion, 852 Marchand, 595 Marjolin's ulcer, 817 Marshall, 340 ]Marsupialization, 608 Martin bandage, 976 Martin, Claude, 814 Martin, Edward, 297, 329, 351, 355, 446 Massachusetts General Hospital, 64, 93, 217, 303, 334 Massage, 62, 732, 762 of prostate, 413, 444, 853 Mastitis, 529 ]\Iatas, Rudolph, 482, 560, 561, 772, 788, 790, 792, 923, 978 splint, 922 Maunsell, 112 Maydl, 389 Mayo, C. H., 214, 282, 586, 601 vein enucleator, 775 Mayo, W. J., 60, 80, 82, 112, 135, 148, 149, 150, 151, 162, 184, 217, 222 McArthur, L. L., 436 McBumey, Charles, 17, 27, 212 incision, low, 32, 40 method, 32 McCosh, A. J., 25, 386 McDowell, Ephraim, 338 McEwen, 20, 21, 212 McGraw, SO McGuire, Hunter, 780 ]\Iechanical therapeutics, 795 Meconium, 91 Meier, 267 Melanoma, 836 Melanosarcoma, 836 Melena, 132 Membranous enteritis, 63 Meningeal tumors, 650, 686 Meninges, 619, 642 Meningitis, 647 epidemic, 680 serosa, 648, 681 spinal, 680 suppurative, 680 urotropin in, 649 Meningocele, 643, 681 ami 438, 70, 780, 145, 218. Meningomyelocele, 681 Mesenteric embolism, 71 thrombosis, 71 Mesentery, 87 cyst of, 821 injuries and diseases of, 87 Metatarsal bones, 917 Metritis, acute, 263 chronic, 267 symj)toms of, 2()S treatment of, 2()S Meyer, Willy, 483, 794, 795, 854 Milk-leg, 773 Miner's elbow, 809 Minor surgery, 719 Mirault, 53(5 Mixter, S. J., 119, 120 Moles, 839 Molluscum fibrosum, 617 ]Monks, George H., 43 Montgomery, 392 IVIoore, E. M., 889 Morf, P. F., 240 Morgagni, 415 Moriarty, 921 Morris, Robert T., 27, 170, 329 Morrison, 163 Morton's fluid, 684 Mosher, H. P., 116 Mott, Valentine, 617, 777 Moynihan, B. G. A., 135, 140, 167, 176, 187, 189, 221, 222, 233 Mucous colitis, 63 polypi, 106 Mailer's ducts, 319 Mulligan, E. W., 304 Mulon, 596 Mummery, 768, 771 Munro, J. C, 135 Murphy button, 42, 69, 81, 199 Murphy, F. T., 230, 482, 977 Murphy, John B., 26, 40, 56, 112, 232, 234, 238, 515, 519, 671, 678, 080, 681, 686, 688, 707, 792, 884 Musculospiral paralysis, 716 Myelocystocele, 682 Myelogenous leukemia, 190, 191 ]\Iyeloid, 832 Myeloma, 651, 685 Myofibroma, 837 Myoma, 292, 837 complicating j^regnancy, 304, 305 intramural, 293 submucous, 293, 294 subserous, 293, 298 uterine, symptoms of, 293 treatment of, 296 Myomectomy, 299 Myositis, 802 Myxoma, 837 of breast, periductal, 524, 525 Myxomatous degeneration, 837 Nail, ingrowing, 757 Nasal bones, 917 defects, 544 INDEX loo-; Niisoj)li;irynx, 57(i Neck, burns ol', 58G carcinoma of, 549 contractions of, cicatricial, 586 dissection of, 552 hydrocele of, 594 lyinpli-nodes of, 589 wiy, 58G Necrosis, 945 fat, 183 phosphorous, 569 Necrotic caries, 559 Neisser, gonococci of, 435 Nelaton, 536, 960 forceps, 339 Nelaton 's line, 896 Neoplasm, 818 Nephrectomy, 378 Nephritis, chronic, 386 NephroHthiasis, 369 Nephroptosis, 243, 246, 247 Nephrotomy, 373, 378 Nerve cocainization, 976 Nerves, anastomosis of, 711 in stump, 710 grafting of, 711 injuries of, 710 intercostal, 716 operations upon, 707 peripheral, 694 peroneal, 716 phrenic, 713 pneumogastric, 713 regeneration of, 707 suture of, 707, 708 wounds of, 710 Neudorfer, 979 Neuralgia, intercostal, 504 major, 698 minor, 698 reHex, 698 Neurasthenia, 61 Neurectomy, tri-facial, 700 Neurilemma, 671 Neuritis, 695 - optic, 641 Neurofibroma of scalp, 617 Neuroma, 709, 838 amputation, 709 Neuromimesis, 872 Neuroplasty, 708 Neuroses, 674 Nevus, 776 cavernous, 556 simple, 556 treatment of, by boiling water, J. ■ Wyeth's, 557 NichoUs, Albert G., 820 Nichols, Edward H., 944, 945, 953 Nicoll, 215 Nipple, disease of, Paget's, 512, 531 supernumerary, 532 Nitze apparatus, 363 Noble, G. H., 276, 282, 285, 350, 356 Noble's operation, 350 Nodular goiter, 602 A. Noma, 560 Non-union, 852, 853 Nothnagel, 48, 154 Nuck, canal of, 280, 330 Obstruction, intestinal, 47, 182 acute, 48 diagnosis of, 50 pathologj' of, 49 chronic, 53, 68 symptoms of, 53, 68 treatment of, 54 pyloric, 128, 139 treatment of, 140 Obturator, 192 Occlusion of rectum, 90 Ochsner, A. J., 35, 214, 229, 230 treatment, 36 Odiorne, Walter B., 464 Odontoma, 561, 840 follicular, 562 0'D^^•yer, 579 intubation, 580 Omentum, diseases of, 87 injuries of, 87 Oophorectomy, 338 Optic neuritis, 641 Orchidectomy, 427, 428, 470 OrcWtis, 468 Organic head lesions, symptoms and diagnosis of, 634 lesions, symptomatology of, 641 stricture, 455 treatment of, 456 Orthopedic surgery, 943 Os calcis, 916 Osgood, Robert B., 812, 959 Osier, William, 65, 67, 154, 190, 224, 227 Osteitis deformans, 953 Osteogenesis imperfecta, 952 Osteoma, 828 Osteomalacia, 952 Osteomyelitis, 559 acute, 946 chronic, 948 Osteoplastic craniotomy, 663 resection of spine, 693 Osteopsathyrosis, 952 Osteosarcoma, 832 Otis's dilating urethrotome, 457 urethrometer, 457 Outerbridge, 351 Ovarian cyst, 334 twisted, 336 tumor, symptoms of, 336 comphcating pregnancy, 339, 341 Ovaries, 319, 331 hematoma of, 336 operations on tubes and, conservative, 329, 332 1 papilloma of, 335 tumors of, solid, 336 Ovariotomy, 333, 338 Ovaritis, 322, 331 I acute, 332 1008 IXDKX Ovaritis, chronic, 332 tulHTculous, 332 Ovula Xal)otlii, 269 Pacchionian f^ranulationw, 043 Pacliynieninjjitis, 047 Paget, Sir James, 197, 198, 227, 953 Paget 's disease of nipple, 50S, 512, 531 Painter, C. ¥., 240, S12 Palmar abscess, 745, 749 Brooks' incision for, 751 Pamijiniform plexus, 331 Pancreas, 181 cysts of, 185, 186 sclerosis of, 182 tumors of, 184 Pancreatic apoplexy, 181, 183 calculi, 1§3, 184 ducts, 169 Pancreatitis, 128, 181, 182, 183 acute, 181 chronic, 181, 183 sub-acute, 183 Papillary cystadenoma, 526 Pajiilloma, 106, 838 of ovaries, 335 of rectum, 100 villous, 839 Paralysis, facial, 712 musculospiral, 710 Paranephritic abscess, 379 Paraphimosis, 439, 440 Parasitic theory of cancer, 820 Parathyroid glandules, 597, 598, 599, 008 tumors, 01 1 Para-urethral abscess, 452 Pare, Ambroise, 490, 031, 070, 734, 772 Park, Roswell, 777, 778, 818, 825, 830, 943, 955, 990 Parker, Willard, 17 Paronychia, 745, 748, 749 Parotid gland, chondroma of, 575 excision of, 575 Patella, dislocation of, 939 fracture of, 904 operation on, 900 Patellae ligamentum, 808 Pathologic fracture, 854, 924 Paul of Egina, 070 Payr, 008 P^an, 127 Pediculi capitis, 594 Pelvic hematocele, 341, 344 viscera, anatomy of, 255 Peh-is, fracture of, 802 Penis, 433 amputation of, 451 cancer of, 450 injuries of, 447 Pennington, J. R., 93 Penski, 163 Peptic ulcer, 129, 133 of esophagus, 127 treatment of, 133 perforating, 142 Perforation, intestinal, 05 of uterus, 275 symptoms of, 65 typhoid, 64 Pericardial effusions, 497 Pericardiotomy, 498 Pericarditis, 497 Pericardium, 490 operations upon, 497 Periductal connective tissue, 522 fibroma of Ijreast, 524 myxoma, 524, 525 sarcoma, 524 Perigastritis, 128 Perineal lacerations, 345 lithotomy, 404 prostatectomy, 420, 423, 426 section, 454 urethrotomy, 453 Perineum, 345 muscles of, 258 operation for repair of, 346 Perineuritis, 095 Periosteal fracture, 854 Periostitis, 945 Peripheral nerves, 094 Perithelioma, 835 Peritoneum, 223 teratoma of, 242 Peritonitis, 28, 49, 73, 182, 186 acute, 223 circumscribed, 49 diffuse, 49 chronic, 234 adhesive, sclerosing, 235 diffuse, 28, 225, 228 symptoms of, 226 treatment of 228 exudative, 234 general, 225, 228 hysteric, 227 idiopathic, 225 localized, 224 malignant, 238 sources of, 226 subphrenic, 224 tuberculous, 236 operation for, 238 Peroneal nerve, 716 Pessary, 279, 285, 289 Peters, 389 Petersen, W. P., 107 Pfannensteil, 282 Phalanges, 895 of foot, 917 fracture of, 895 Phalanx of thumb, dislocation of first, 934 Phantom tumor, 76 Pharynx, 570 Phelps, 212 Phimosis, 439 Phlebitis, 773 obliterans, 773 Phlegmasia alba dolens, 772 Phloridzin test, 305 INDEX 1009 Phosphorus necrosis, 569 rhrcnii' ncrvo, 713 I'ia mater, ()43 Piles, W, 100 straufiuhited, 100 Pin worms, 03 Piropioff's ojieration, 9^3 Pituitary body, (J57 Plastic operations on face, 544 resection of breast, 527 Playfair, 318 Pleura, 4SS echinococcus of, 495 tumors of, 495 Pleurisy, 489 . Pleuro-peritoneal cavity, 194 Plexiform angioma, 776 Plummer, 119 Pneumatic suit, 770, 977 Pneumogastric nerve, 713 Pneumonia inhalation, 584 Pneumonotomy, 481 Polk, 329 Polypi, 271 in uterus, 293 mucous, 106, 269 Ponfick, 162 Porro's operation, 305 Portal circulation, 73 vein, 169 Porter, Charles Allen, 71, 767 Porter, Charles Burnham, 17 "Port-wine stain," 556 Postenski, 212 Posteriortibial art-eiy, 780 urethritis, 440 wire spUnt, Cabot (A. T.), 910 Posthitis, 439 Posture, knee-chest, 111 Pott, Percival, 7^9, 913 Pott's fracture of fibula, 913 Poultices, 746 Pt3wder, face, 545 Powers, Charles A., Ill, 189 Precancerous conditions, 845 Pregnancy, abdominal, 341 extra-uterine, 340, 341 ovarian, 341 tubal, 340 Prepatellar bursitis, 809 Probang, 114 Procidentia uteri, 277, 288, 349 treatment of, 289 Proctitis, 93, Proctoclysis, 234, 770 Proctoplasty, 92, 105 Proctoscope, 90, 93, 104 Proctotomy, 104, 105 Prolapse of anus, 102 of rectum, 103 of spleen, 187 of stomach, 245 of uterus, 288 Prostate, 388, 411 anatomy of, 411 calculi of, 414 64 Prostate, cancer of, 415, 428 excision of, 429, 430 enlarged, 390, 415 sym])t()ms of, 41() inflamnuition of, 412 massage of, 413, 444 sarcoma of, 432 Prostatectomy, perineal, 420, 423, 426 suprapubic, 416, 420, 421 Prostatitis, acute, 439 chronic, 414 treatment of, 413 tulserculous, 414 Proud flesh, 741 Pruritus ani, 93 Psammoma, 828 Pseudocyst, 185, 186 Psychic aspects of Graves' disease, bOl Psychoses, 662 Pterion, 637 Ptosis, 128 abdominal, 243 bandage for, 166 gastric, 61 of liver, 62 visceral, 63 Pulmonary actinomycosis, 486 tuberculosis, 485 Puncture of bladder, suprapubic, 394 lumbar, 648 Punctured fracture, 622 Purmann, 772 Putnam, James J., 699 Pyelitis, 375, 378 Pylorectomy, 127, 140, 149 Pyloric obstruction, 128, 139 I stenosis, 131, 145 hypertropliic, 145 in infants, 129, 141 Pyloroplasty, Finney's, 134, 140 Pylorus, spasm of, 129, 144 Pyonephrosis, 377 Pyopneumothorax, 131, 224 Pyosalpinx, 320 Pyothorax, 490 QuiMBY, W. C, 71, 438 Quincke, 648 Radial arteiy, 780 Radius, head of, dislocation of 933 head and neck of, fracture of, 88b neck of, fracture of, 881 Ranula, 547, 823 Pawling, L. B., 626 Rectal lymphatics, 109 tenesmus, 79 valves, hypertrophy of, 90 Rectocele, 346, 347 Rectopexy, 104 c of:a Rectovaginal fistula, 353, 355, 356 Rectum, cancer of, 106, 107 imperforate, 90 inflammation of, 92 1010 INDEX Rectum, iiiflainmation of, gonorrheal, 93 occlusion of, 90 papilloma of, lOti proluj).sc of, 103 resection of, 109 anal nicthotl, 109 conihinod, 1 10 dorsal, 110 sacral, 1 10 stricture of, 104 sypliilitic affection ot, 94 tuberculosis of, 94 tumors of, 106 ulcer of, 93 Reed, 351, 935 Regeneration of nerves, 707 Reichmann's disease, 144 Reinlmch, 99 Renal calculi, 370 treatment of, 381, 382 disease, diagnosis in, 360 Resection of breast, plastic, 527 of jaw, upper, 565 of jaws, upper and lower, 564 of rectum, combined method, 110 dorsal method, 110 sacral method, 110 of ribs, 491 of sigmoitl, 80 of sj)ine, osteoplastic, 693 Retention cysts, 820 of breast, 532 of urine, 389, 390 Retrocecal fossa, 76 Retroduodenal fossa, 76 Retroflexion of uterus, 284, 285 Retroperitoneal cysts, 241 hernia, 193 lymph nodes, tuberculosis of, 239 space, 238 tumors of, 241 Retroversion of uterus, 276 treatment of, 279 Reynolds, Edward, 241, 329, 345 Rhinoplasty, 545 f'odman's (E. A.), 546 Rhinorrliea, cerebrospinal, 645 Rib, cervical, 597 fracture of, 859 resection of, 491 Ribbert, 21 Richardson, Maurice Howe, 17, 93, 122, 123, 124, 190, 338 Rickets, 951 Ricketts, B. M., 481 Ricord, PhilUpe, 434 Ridlon, 898 Riebold, 122 Riedel's lobe, 167 Riva-Rocci apparatus, 721 Robinson, Samuel, 894 Robson, Mayo, 184 Robson's point, 169 Rodent ulcer, 554, 618 Rogers, John, 601 Rokitansky, 75, 960 Rolando, fissure of, 638 Rosary, 951 Rose, 543 position, 584 Rotcii, Thomas Morgan, 240 Rotter, 212, 514 Roux, 140, 141, 534, 605 operation, complete, 140 Russell, R. Hamilton, 194 Rutkowski, 389 Rydygier, 127, 167, 191, 355 Sacculation of bladder, 408 Sactosalpinx hemorrhagica, 320 purulenta, 320 serosa, 320 Safety-pin, 56, 92 SaUne infusion, 771 Salivary fistula, 547 glands, 574 stone, 547 Salpingectomy, 326 Salpingitis, 319 catarriial, 319, 325 purulent, 319 symptoms of, 322 treatment of, 325 tuberculous, 320, 322, 324 Sampson, Jolm A., 315, 316 Sandelin's cheiloplasty, 552 Sanger, 318, 355 Santorini, duct of, 169, 181 Sarcoma, 829 giant-cell, 832 of breast, periductal, 524 of esophagus, 125 of intestines, 77 of jaw, 563 of kichiey, 384 of lung, 486 of prostate, 432 of stomach, 153 of testicle, 476 of tongue, 574 of uterus, 317 Sargent, Percy W. G., 197 Sausage-shaped tumor, 74 Savoiy, William S., 767 Scalp, avulsion of, 616 closing, Cushing's method of, 667 contusion of, 614 cysts of, dermoid, 617 hematoma of, 615 neurofibroma of, 617 tumors of, 616 wounds of, 615 Scannell, David D., 233, 854 Scai)hoid, fracture of, 892 Scapula, fracture of, 867 Scars, malignant degeneration of, 817 Scliandinn, 444 Scliede, 212, 372 Scliede's operation, 482, 493, 494, 775 Scheele, 369 Schiassi's operation, 165 INDEX 1011 Schimmplbusch, M5 Schiuii'dcu, N'ictor, 7!)4, 795 Schroder, 270, :i2\) Schroder's operation, 270 Schulz, 495 Schwann, sheath of, 671 Sclerosis of pancreas, 182 Sciatica, 705 Sciatic hernia, 192 Scrotal hernia, 192 Scudder, Charles L., 141, 207, 208, 209, 251, 408, 477, 850, 856, 859, 862, 864- 866, 868, 869, 871-878, 880, 882-885, 888-892, 894, 895, 898, 900-902, 904, 909-919, 921, 922, 926, 928, 929-933, 936, 941 Section, perineal, 454 Seelig, M. G., 41, 125 Seeping method, 40, 234 Semilunar cartilage, 940 Senn, Nicholas, 188 Sequestrum, 945 Serous meningitis, 681 Serum, horse, 814 Shattuck, Frederick, C, 237 Sheath of Schwann, 671 Sheen, 768 Sheldon, John G., 37 Sherrington, 638 Shipton, 42 Shock, 767, 976 diagnosis of, 769 treatment of, 769, 772 Shoulder, dislocation of, 927 old unreduced, 931 Shoulder-joint amputation, 991 Sigmoid flexure, diverticula of, 59 resection of, 80 Sigmoidopexy, 104 "Silver-fork" deformity, 886 Simon, 358, 389, 536 Simmons, Channing C, 464 Sims, Marion, 353 Sims' position, 354 speculum, 354 Singley, J. D. V., 543 Sinus thrombosis, 646 tuberculous, 503 Skin, 812 _ disinfecting, 725 Skull, 619 fracture of, 620 opening, 664 Small, E. H., 91 Smith, H. L., 880 Smith, Nathan, 338 Smith, Stephen, 985 Smith, WilUam H., 237 Smyth, A. W., 777 Sobotta, 193, 239, 258 Society of Clinical Surgery, Frontispiece and 71 Sounding for stone, 399 Sounds, bulbous, 113 Schreiber's dilating, 114 ' Starck's diverticulum, 114 Spasm, facial, 712 of i)yl()rus, 129, 144 Spasmodic stricture of urethra, 454 torticollis, 587, 588, 713 Spasticity, 642 Spear, Walter M., 188 Spermatocele, 471, 474 Spiller, William G., 613, 709 Spina bifida, 681, ()82, 683, 684 Spinal meningitis, 680 Spine, 613, 669 concussion of, 674 contusion of, 674 "railway," 674 resection of, osteoplastic, 693 tumors of, 685 Spinofacial anastomosis, 711 Spiral fracture, 854 Splanchnoptosis, 243 Spleen, 187 abscess of, 188 cysts of, 188 pathologic, 187 prolapse of, 187 ptosis of, 190 rupture of, 187 tuberculosis of, 188 wandering, 191, 250 wounds of, 187 Splenectomy, 187, 188, 189, 190, 191 Splenic anemia, 190, 799 ' enlargement, 189 leukemia, myelogenous, 191 Splenomegaly, 190 Splenopexy, 191 Rydygier's, 167 Splenoptosis, 243 Splint, Cabot's posterior wire, 910 Cobb's, 918 CooUdge's, 918 Desault, 913 Dupuytren's, 915 Matas, 922 Thomas hip, 898 Splints, applying, 731 types of, 855 Spondylitis deformans, 972 "Spotted fever," 648 Sprain, 956 "Stab wound," 177, 178 Staffordshire knot, 339 Starr, M. Allen, 613 Steno's duct, 547 Stenosis, intestinal, 69 of pylorus, 131, 145 hypertrophic, 145 in infants, 129 Sternum, fracture of, 861 Stewart, 695 Stimson, L. A., 859, 932, 937 Stinson, J. Coplin, 461 Stinson's operation for hypospadias, 460 Stomach, 113, 127, 168 cancer of, 145 distortion of, 129, 131, 142 hour-glass, 129, 131, 142 1012 INDEX Stomach, lymphatics of, 146 prolapse of, 243 sarcoma of, I5'.i wounds of, 154 Stone, Arthur K., 184, 243 Stone in bladder, 398 in kidney, 3G9 salivarj', .")47 sounding for, 399 Storer, Malcolm, 32(1, 329, 337, 340 Strangulated hernia, 19G, 197, 198 piles, 100 Strangulation, intestinal, 50, 51 Streptothrix, 70 Stricture, acquired, 454 inflan^matorj-, 455 of esophagus, 114, 115 diagnosis of, 118 treatment of, 118 of rectum, 104 organic, 455 spasmodic, 454 traumatic, 452 urethral, 452 Struma, 602 Strumpell, 652 Study of cases, 719 Stump, ners-e anastomosis in, 710 painful, 980 Subdeltoid bursa, 808 Subdural hemorrhage, 628 Subinvolution of uterus, 268 Suboccipital exploration, 667 Summers, J. E., 190 Suppurative leptomeningitis, 648 meningitis, 680 urotropin in, 649 Supracondyloid fracture of femur, 903 Suprapatellar bursa, 808 Suprapul)ic cystotomy, 402 prostatectomy, -416, 420, 421 Suprarenal gland, 382 tumors of, 386 Surgical kidnev, 376, 377, 378 Sutclitfe, W. G., 592 Suture of blood-vessels, 792 of nerves, 707, 708 Sylvius, fissure of, 638 Syme's operation, 982 Synovitis, 956 Syphilis, 434 genital lesions of, 444 of anus, 94 of bone, 949 of breast, 531 of liver, 160 of rectum, 94 Syphilitic epididymitis, 468 orchiditis, 468 Syringomyelocele, 681, 682 Tait, Law-son, 297, 347, 356 operation, 356 Talma, 163, 164, 167 Tape, absorbent, 733 Taxis, 185 Tavlor, Alfretl S., 539 Taylor, K. W., 690 Teale's amputation, 986 Tendon, 801, S03 conjoined, 206 slieaths, tumors of, 806 transplantation, 808 wouiuls, S06 Tendoplasty, 807 Tenesmus, rectal, 79 Tenosynovitis, 804 tuberculous, 805 Teratoma, 824 of peritoneum, 242 of testicle, 476 Terrier, 64, 165 Testicles, absence of, 467 adenoma of, 476 cancer of, 476 cysts of, dermoid, 476 inflammation of, 468 sarcoma of, 476 tuberculosis of, 469 tumors of, 475 xmdescended, 464 wounds of, 468 Tetany, gastric, 129, 144 Thecitis, 804 Therapeutics, mechanical, 795 Thigh, fracture of, 903 Thomas collar, 123 hip splint, 898 Thompson, George, 141, 363 Thompson, Heniy, 366 Thoracentesis, 48*9 Thoracic duct, wounds of, 593 Thomdike, Paul, 384 Three-glass test, 441 Thrombosis, mesenteric, 71 sinus, 646 Thumb, dislocation of first phalanx of, 934 Thyroglossal cysts and ducts, 548 Thyroid, accessor^-, 598 fracture of, 579 glantl, 597 cancer of, 610 inflammation of, 611 Thyroidectomy, 607 Thyrotoxic disease, 599, 600 Tibia, rupture of tubercle of, 908 Tibial arten,% anterior, 782 posterior, 780 Tic douloureux, 698 convulsive, 712 Tileston, Wilder, 127, 164 Tillmanns, 162, 624 Toe-nail, ingrowing, 758 packing, 760 Toes, amputation of, 981 Toldt, 671 Tongue, 569 abscess of, 571 cancer of, 571 operation for, 572 INDEX 1013 Toiiiiiie, infl;iiniii;itii)n of, .")7() sarcoma of, .")7 I tie, 570 tuhorculosis of, .■>71 tmnoi-s of, non-malii^naut, 574 wounds of, '■>70 Tonsil, tvimors of, 570 Torticollis, .'jSC) spasmotlic, 587, 588, 713 Toxins of eiysipelas, 848 Trachea, foreign boily in, 579 Transfusion of blooil, 368 Transposition of viscera, 5i) Traumatic aspliyxia, 502 bursitis, treatment of, 809 neurosis, 674 stricture, 452 Treitz, ligament of, 135 Trendelenlnirg, F., 212, 774 position, 195, 207, 256, 355 Treves, Frederick, 76, 614 Trichina spiralis, 803 Trichiniasis, 803 Trifacial neurectomy, 700 Truss, 203, 204 TiTpsin treatment, 848 Tubal abortion, 340, 341 pregnancy, 340 rupture, 340, 341, 342 Tube, Einhorn-Jackson-Mosher, 116 Symoiid's esophageal, 110 T-, 324 Tuberculosis, ileocecal, 69 of anus, 94 of bone, 948 of burs£e, 812 of intestines, 67 of joints, 960 of kidney, 380 of retroperitoneal lymph nodes, 239 of rectum, 94 of spleen, 188 of testicle, 469 of tongue, 571 pulmonary, 485 renal, 381, 382 Tuberculous adenitis, treatment of, 591 cystitis, 395 disease of breast, 531 ganglion, 806 lympli nodes, 799 ovaritis, 332 peritonitis, 236, 238 prostatitis, 414 salpingitis, 320, 323, 324 . sinuses, 503 tenosynovitis, 805 ulcers, 58 Tubular diarrhea, 63 Tulndocysts, 820 Tumors, benign, 818 causation of, 819 cavernous, 776 cerebellar, 656 connective-tissue, 826 epithelial, 838 Tumors, fecal, 57 intracranial, ()54 intramedullary, 689 intraspinal, laminectomy for, 694 malignant, 8 IN meningeal, 650, 686 of alxlominal wall, 252 of anus, 105 of bladder, 405 diagnosis of, 406 of brain, (553 sym])toms of, 655 treatment of, 657 of breast, ^^'arren's classification of, 523 of broad ligament, 330 of bursEP, 812 of cauda equina, 689 of chest-wall, 504 of conus medullaris, 689 of cranial bones, 650 of esophagus, 125 of face, 556 of Fallopian tubes, 329 of intestines, 76 benign, 77 of jaw, 561 of kidney, 382 cystic, 385 of larynx, 583 of Hver, 159 treatment of, 161 of pancreas, 184 of pleura, 495 of retroperitoneal space, 241 of rectum, 106 of scalp, 616 of spine, 685 of suprarenal gland, 386 of tendon-sheaths, 806 of testicle, 475 of tongue, 574 of tonsil, 576 of umbilicus, 254 of uterus, 292 ovarian, complicating pregnancy, 339 solid, 336 symptoms of, 336 parathyroid, 611 phantom, 76 round ligaments, soUd, 331 sausage-shaped, 74 Tunica vaginalis, hydrocele of, 471 Tuttle, 102 Twisted cord, 477 Ulcer, acute, 129, 130 chronic, 129, 130 duodenal, 30, 129, 130, 131, 133, 144, 173 malignant degeneration of, 817 Marjolin's, 817 of bladder. 404 treatment of, 405 of esophagus, 127 peptic, 127 1014 INDEX I'lcer of leg, 742 of rectum, 93 peptic, 128, 129, 130, 133 perforating, 142 rodent, 554, 618 varicose, 740, 742 T'ltzmann's syringe, 437 I'nihilicus, inflammations about, 254 malformations of, 253 tumors of, 254 Upper extremity (shoulder girdle), am- putation of, 989 jaw, fracture of, 920 I' radius, malformations of, 253 Ureteral calculi, 371, 373 catheter, 364 Ureter, 359 and cervix uteri, relations of, 259 double, 360 injuiy of, 375 kinking of, 375 Urethra, 433 anatomy of, 433 calculus of, 452 foreign body in, 451 stricture of, 452 Urethral caruncle, 352 fistula, 458 Urethritis, non-specific, 435 posterior, 440 Urethrometer, Otis's, 457 Urethroscopy, 458 Urethrotome, Otis's dilating, 457 Urethrotomy, perineal, 453 Urethrovaginal fistula, 353, 354 Urinaiy calculi, symptoms of, 370 Urine, incontinence of, 397 residual, 417 retention of, 397 segregating, 364 Urotropin, 667 in suppurative meningitis, 649 Uterosacral ligaments, 279 Uterus, 255 adenocarcinoma of, 306 anteflexion of, 285 Dudley's operation for, 286 anteversion of, 276, 284 cancer of, 305 diagnosis of, 309 symptoms of, 308 treatment of, 309 pan-hysterectomy for, 317 deciduoma malignum (choriodecidu- oma), 318 descent of, 288 displacements of, 275 endothelioma of, 317 inflammations of, 261 lacerations of, 272 lymphatic connections of, 257, 260 myoma of, symptoms of, 293 treatment of, 296 perforation of, 275 polypi in, 293 procidentia of, 277, 288, 289, 290 Uterus, retroflexion of, 284, 285 retroversion of, 276 sarcoma of, 317 steaming, 297 subinvolution of, 268 suspension of, 280 through abdominal section, 281 through vagina, 281 tumors of, 292 wounds of, 274 Vaccine therapy, 251 Vagina, atresia of, 357 ^'aginal cysts, 357 fistula, 353 process, 194 Vaginitis, 357 Valve of Gerlach, 18, 20 Valvulse conniventes, 43, 44 Vander Veer, Albert, 821 van Hook, 375 van Kaathoven, 709 van Zwalenburg, ('., 21 Varices, 99 Ijinph, 796 Varicocele, 474 of broad ligament, 331 Varicose aneurj-sm, 776 iilcer, 740, 742 veins, 774 Varix, aneuiysmal, 776, 784, 791 Vasa recta, 45 Vasectomy, 427 Vaughan, George T., 500 Vein enucleator, Mayo's, 775 portal, 169 Venereal warts, 448, 762 Ventral hernia, 192 Ventrofixation, 290 Ventrosuspension, 290 "N'erruca, 448 acuminata, 761 filiformis, 761 senilis, 761 vulgaris, 761 Vertebrae, dislocation of, 676 fracture of, 676 Verumontanum, 434 Vesico-uterine fistula, 353 Vesico-utero vaginal fistula, 353 Vesicovaginal fistula, 353, 354, 355 Vessels, lymjjh, 796 Villous papilloma, 839 Vincent, Beth, 25 Virchow, 60, 243, 505, 960 Viscera, pelvic, anatomj' of, 255 transposition of, 59 Visceral ptosis, 63 Vitello-intestinal duct, 57, 253 Volkmann's contracture, 801, 802 Volvulus, 73, 75 Vomit us, coffee-ground, 132 von Bergmann, 212, 225, 625, 630 von Dittel. 355 von Eiciien, 479 INDEX 1015 von Graefe, 534 von }l:ill(>r, ,V.)5 von J.;in,<;('ul)('ck, fy',M], 543 von Mikulicz, 7